Mus Pre-Participation Medical History Form - 2016-2017
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8** PLEASE PRINT **
MUS Pre-participation Medical History Form
201 -
Full Name: __________________________________________________________
Grade:________
Sex:
M
F
DOB: ______/______/______
Age:______
Sport(s):_______________________________________________________
Family/Personal Physician(s): ______________________________________________
Phone:_______________________
INSTRUCTIONS: Circle “YES” or “NO” for each question.
Please EXPLAIN all “YES” responses below--Be specific
HAVE YOU EVER:
YES
NO
1. Been hospitalized?
YES
NO
2. Had any surgery?
YES
NO
3. Passed out or fainted during exercise?
YES
NO
4. Become dizzy during or after exercise?
YES
NO
5. Had chest pain during or after exercise?
YES
NO
6. Had high blood pressure?
YES
NO
7. Been told that you have a heart murmur?
YES
NO
8. Had a racing heart rate or skipped heartbeats?
YES
NO
9. Had anyone in your family die from heart-related
problems or sudden death prior to age 50?
YES
NO 10. Had a serious head injury?
YES
NO 11. Been knocked out or unconscious?
YES
NO 12. Had or suffered any type of seizure?
YES
NO 13. Had a “stinger”, “burner” or pinched nerve?
YES
NO 14. Had heat or muscle cramps?
YES
NO 15. Been treated for heat exhaustion or heat stroke?
YES
NO 16. Been dizzy or passed out in the heat?
YES
NO 17. Had trouble breathing or coughing during or after activity/exercise?
YES
NO 18. Had any problems with your eyes or vision?
YES
NO 19. Sprained, strained, dislocated or fractured a bone?
(Check all that apply)
__Head
__Neck __Shoulder __Elbow __Forearm __Wrist / hand / fingers __Chest
__Back
__Hip __Thigh
__Knee __Shin / calf __Ankle __Foot / toes
____________________________________________________________________________________________________
YES
NO 20. Had or suffered from other medical conditions? (Hepatitis, Meningitis,
Mononucleosis, Asthma, Epilepsy, Diabetes, etc..)
YES
NO 21. Been advised by medical personnel not to participate in athletic-related activities?
Reason: ___________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
. Do you have sickle cell trait, or have a family history of sickle cell trait? If “YES” to__
YES
NO 22
_______________________________________________________
either, please explain.
DO YOU:
YES
NO 23. Have any known allergies? Please list:
YES
NO 24. Currently take any medications? Please list:
YES
NO 25. Often tire out more quickly than your friends during exercise?
YES
NO 26. Have any skin problems (rashes, itching, acne, etc..)?
YES
NO 27. Wear (Check all that apply):
__glasses?
__contact lenses?
__protective eyewear?
_______
YES
NO 28. Wear or use any special braces or equipment?
YES
NO 29. Currently have any medical problems (since your last medical evaluation)?
YES
NO 30. Have any religious beliefs that would NOT allow you to be treated by a physician or medical facility should
you become injured or seriously ill?
30. What was the date of your: Last tetanus shot?__________
Last measles immunization?______________
_
_______
I/We hereby state that, to the best of our knowledge, the information given above is complete and accurate.
___________________________________
_________________________________________
_____/______/_____
Athlete’s Signature
Parent/Guardian’s Signature
Date
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Parent category: Medical