Medical History Questionnaire Form printable pdf download

MacMurray College HighlanderMedical History Questionnaire

(page 1 of 2)

To be completed by athlete or parent prior to examination

Name _______________________________________________________________ Sport(s)___________________________

Last

First

Middle

Address _____________________________________________________________ Phone ____________________________

Social Security Number _________________________Birthdate ________________ Age ____________Class Rank_________

Parent’s Name(s) _______________________________________________________________________________________

Address _____________________________________________________________ Phone ____________________________

Person to contact in case of emergency ____________________________________Phone ____________________________

Family Doctor ______________________________City/State __________________Phone ____________________________

Past Medical History

Yes

If yes, explain

(what, where, when)

1. Have you been diagnosed with asthma?

_____

_______________

2. Have you been prescribed by a physician to use asthma medication?

_____

_______________

3. Do you have a current consent form to self-administer the asthma medication on

file with your school?

_____

_______________

4. Allergic to medicine, foods, bee stings?

_____

_______________

5. Wears glasses, contact lenses?

_____

_______________

6. History of braces, chipped teeth, bridges?

_____

_______________

7. Has ongoing medical problem?

_____

_______________

8. Had serious or significant illness in past?

_____

_______________

9. Any past surgical operations, accidents, non-sports or related injuries?

_____

_______________

10. Any known deformities (such as curvature of back, heart, kidney, blindness, etc?)

_____

_______________

11. Any serious family illness (such as diabetes, bleeding disorders, etc.)?

_____

_______________

12. Family history of cancer?

_____

_______________

13. Heart

Have you ever passed out during or after exercise?

_____

_______________

Do you get tired more quickly than your friends do during exercise?

_____

_______________

Have you ever had racing of your hear or skipped heartbeats?

_____

_______________

Have you had high blood pressure or high cholesterol?

_____

_______________

Have you ever been told you have a heart murmur?

_____

_______________

Has any family member or relative died of heart problems or of sudden death

before age 50?

_____

_______________

Have you had a severe viral infection (ex; myocarditis, mononucleosis) within the

last month?

_____

_______________

Has a physician ever denied or restricted your participation in sports for any

heart problems?

_____

_______________

Has anyone in your family had a heart attack before the age of 50?

_____

_______________

14. Head and Nerve

Have you ever had a head injury or concussion?

_____

_______________

Have you ever been knocked out, become unconscious, or lost your memory?

_____

_______________

Have you ever had a seizure?

_____

_______________

Do you have frequent or severe headaches?

_____

_______________

Have you ever had numbness or tingling in your arms, hands, legs or feet?

_____

_______________

Have you ever had a stinger, burner, or pinched nerve?

_____

_______________

Medical History Questionnaire Form

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