Medical History & Physical Exam Questionnaire Form printable pdf download

MC Medical History and Physical Exam Questionnaire

Recommended by the MIAA

PART A ~ HISTORY

DATE of EXAM _____________

Student’s Name _________________________________________ Sex _______ Age __________ Date of Birth _____________

Grade_____ School _____________________________________________ Sport(s)___________________________________

Address ______________________________________________________Tel________________________________________

Physician _____________________________________________________Tel________________________________________

IN CASE OF AN EMERGENCY, CONTACT:

Name Relationship______________________ Tel (H) ___________________________ (W) _______________________

EXPLAIN “YES” ANSWERS BELOW. CIRCLE QUESTIONS YOU DON’T KNOW THE ANSWERS TO.

YES

1. Have you had a medical illness or injury since your last check up or

21. Have you ever had a seizure?

sports physical?

2. Have you ever been hospitalized overnight?

22. Do you have frequent or severe headaches?

3. Have you ever had surgery?

23. Have you ever had numbness or tingling in your arms,

hands, legs, or feet?

4. Are you currently taking any prescription or nonprescription (over-the-

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

counter) medications or pills or using an inhaler?

5. Have you ever taken any supplements or vitamins to help you gain or

25. Have you ever become ill from exercising in the heat?

lose weight or improve your performance?

6. Do you have any allergies (for example, to pollen, medicine, food, or

26. Do you cough, wheeze, or have trouble breathing during or

stinging insects)?

after activity?

7. Have you ever had a rash or hives develop during or after exercise?

27. Do you have asthma?

8. Have you ever passed out during or after exercise?

28. Do you have seasonal allergies that require medical

treatment?

9. Have you ever been dizzy during or after exercise?

29. Do you use any special protective or corrective equipment

or devices that aren’t usually used for your sport or position

(for example, knee brace, special neck roll, foot orthotics,

retainer on your teeth, hearing aid)?

10. Have you ever had chest pain during or after exercise?

30. Have you had any problems with your eyes or vision?

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

31 Do you wear glasses, contacts, or protective eyewear?

12. Have you ever had racing of your heart or skipped heartbeat?

32. Have you ever had a sprain, strain, or swelling after injury?

13. Have you had high blood pressure or high cholesterol?

33. Have you broken or fractured any bones or dislocated any

joints?

14. Have you ever been told you have a heart murmur? If yes, please

34. Have you had any other problems with pain or swelling in

explain.

muscles, tendons, bones, or joints?

If yes, check appropriate box and explain below:

Head

Elbow

Hip

Neck

Forearm

Thigh

Back

Wrist

Knee

Chest

Hand

Shin/Calf

Shoulder

Finger

Ankle

Upper

Arm

Foot

15. Has any family member or relative died of heart problems or of sudden

35. Do you want to weigh more or less than you do now?

death before age 50?

17. Has a physician ever denied or restricted your participation in sports

36. Do you lose weight regularly to meet weight requirements

for any heart problems?

for your sport?

18. Do you have any current skin problems (for example, itching, rashes,

Explain “yes” answers here:

acne, warts, fungus, or blisters)?

________________________________________________________________

19. Have you ever had a head injury or concussion?

________________________________________________________________

20. Have you ever been knocked out, become unconscious, or lost your

________________________________________________________________

memory?

________________________________________________________________

I HEREBY STATE THAT TO THE BEST OF MY KNOWLEDGE, MY ANSWERS TO THE ABOVE QUESTIONS ARE COMPLETE AND

CORRECT.

Signature of Athlete/Date _________________________________ Signature of Parent-Guardian/Date________________________________

PHYSICIANS: PLEASE FILL OUT BACK AND RETURN

Medical History & Physical Exam Questionnaire Form

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