Part 2. Medical History (to be completed by student or parent). Explain "yes" answers below. Select questions you don't know answers to.
Have you had a medical illness or injury since you last check up or sport physical? - Yes No
Do you have an ongoing chronic illness? - Yes No
Have you even been hospitalized overnight? - Yes No
Have you ever had surgery? - Yes No
Are you currently taking any prescription or non-prescription (over-the-counter) medications or pills or using an inhaler? - Yes No
Have you ever taken any supplements or vitamins to help you gain or lose weight or improve your performance? - Yes No
Do you have any allergies (for example, pollen, latex, medicine, food or stinging insects? - Yes No
Have you ever had a rash or hives develop during or after exercise? - Yes No
Have you ever passed out during or after exercise? - Yes No
Have you ever been dizzy during or after exercise? - Yes No
Have you ever had chest pain during or after exercise? - Yes No
Do you ever get tired more quickly than your friends do during or after exercise? - Yes No
Have you ever had racing of you heart or skipped heartbeats? - Yes No
Have you had highblood pressure or high cholesterol? - Yes No
Have you ever been told you have a heart murmur? - Yes No
Has any family member or relative died of heart problems or sudden death before age 50? - Yes No
Have you had a severe viral infection (for example, myocarditis or mononucleosis) within the last month? - Yes No
Has a physician ever denied or restricted your participation in sports for any heart problems? - Yes No
Do you have any current skin problems (for example, itching, rashes, acne, warts, fungus, blisters or pressure sores? - Yes No
Have you ever had a head injury or concussion? - Yes No
Have you ever been knocked out, become unconscious or lost your memory? - Yes No
Have you ever had a seizure? - Yes No
Do you have a frequent or severe headaches? - Yes No
Have you ever had numbness or tingling in your arms, hands, legs or feet? - Yes No
Have you ever had a stinger, burner or pinched nerve? - Yes No
Have you ever become ill from exercising in the heat? - Yes No
Do you cough, wheeze or have trouble breathing during or after activity? - Yes No
Do you have asthma? - Yes No
Do you have seasonal allergies that require medical treatment? - Yes No
Do you use any special protective or corrective equipment or medical devices that aren't usually used for your sport or position (for example, knee brace, special neck roll, foot orthotics, shunt, retainer on your teeth or hearing aid? - Yes No
Have you had any problems with your eyes or vision? - Yes No
Do you wear glasses, contacts or protective eyewear? - Yes No
Have you ever had a sprain, strain, or swelling after injury? - Yes No
Have you broken or fractured any bones or dislocated any joints? - Yes No
Have you had any other problems with pain or swelling in muscles, tendons, bones or joints? - Yes No
If yes, check appropriate blank and explain below:
Head
Neck
Back
Chest
Shoulder
Upper Arm
Elbow
Forearm
Wrist
Hand
Finger
Foot
Hip
Thigh
Knee
Shin/Calf
Ankle
Do you want to weigh more or less than you do now? - Yes No
Do you lose weight regularly to meet weight requirements for your sport? - Yes No
Do you feel stressed out? - Yes No
Have you ever been diagnosed with having the sickle cell trait? - Yes No
Record the dates of your most recent immunizations (shots) for:
Tetanus:
Hepatitus B:
Measles:
Chickenpox:
FEMALES ONLY (optional)
When was your first menstrual period?
When was your most recent menstrual period?
How much time do you usually have from the start of one period to the start of another?
How many periods have you had in the last year?
What was the longest time between periods in the last year?
Explain "Yes" answers here:
We hereby state to the best of our knowledge, that our answers to the above questions are complete and correct. In addition to the routine medical evaluation required by s.1006.20, Florida Statutes, and FHSAA By law 9.7, we understand and acknowledge that we are hereby advised that the student should undergo a cardiovascular assesssment, which may include diagnostic tests as electrocardiogram (EKG), echocardiogram (ECG) and/or cardio stress test.
Signature of Student:
Date:
Signature of Parent/Guardian:
Date: