First Year Varsity Athletics Pre-participation Medical Examination
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1 First Year Varsity Athletics Pre-participation Medical Examination Background 1. Name: address: 2. Date of Birth / / 3. Gender: Male Female 4. Academic Class (for the upcoming year) Freshman Sophomore Junior Senior Co-term (concurrently completing a bachelor s and master s degree) Graduate 5. Are you on an athletic scholarship? 6. Varsity sport(s) (Circle all that apply & number of years played) Baseball Softball Basketball Tennis Bowling Track & Field Cross Country Volleyball Football Wrestling Soccer MEDICAL HISTORY 7. How many years has it been since your last complete health examination, other than an examamination that was required for you to participate in sports? 1 year 2 years 3 years more than 3 years Never had a complete health exam other than for sports 8. Are you presently taking any prescribed or over the counter medication? (including birth control pills, insulin, allergy shots, or pills, asthma inhalers, vitamin or mineral supplements including iron, anti-inflammatory including aspirin). Yes (if so, please fill out the table below) NO Name of Medication Dose Frequency of Use
2 9. Do you have an allergy to any? Drug or medicine (over the counter or prescribed) Foods Insects or animals Plants, grasses, pollen, dust or other environmental factors Allergy: 10. Has a doctor ever told you that you have had any of the following medical problems? (if you don t know, mark NO ) Mononucleosis Jaundice Rubella (german measles) Stomach or intestinal ulcer Chicken pox Hernia Repeated sinus infections Eczema Nose fracture Psoriasis Hearing defect or loss Diabetes Recurrent ear infection Sickle cell anemia/carrier Epilepsy anemia Tumor, growth, cyst, cancer Abnormal bleeding or clotting disorder Over-active thyroid Blood clot or embolism Under-active thyroid Leukemia or other blood disorder Arthritis Kidney injury Marfan syndrome kidney disease Oral herpes (cold sores) Frequent urinary infections Genital herpes Depression Injury to liver or spleen mental disorder Hepatitis Birth defect 11. Have you ever had surgery to the following? Month Year If yes, give reason for surgery Eyes Ears/nose/throat Heart Lungs Stomach/bowels/appendix Kidneys Liver/spleen Bone Muscle/ligament/tendon Joint (please specify)
3 12. Were you born with two normal: Eyes Ears Kidneys Yes No 13. Do you presently have the following skin problems: Rash Fungal Infection Cold Sore (s) 14. Have you ever had heat exhaustion/heatstroke/sun stroke? 15. During or after exercise, have you ever: Been dizzy or light-headed? Passed out (fainted)? Had chest pain, discomfort or tightness? Found it more difficult to breath than usual? Had problems with coughing? 16. Have you ever been told that you have a heart murmur? 17. Have you ever had racing of your heart, irregular or skipped beats? 18. Have you ever been told by a doctor that you have had: High blood pressure? Pericarditis, myocarditis, endocarditis (infections of the heart)? Rheumatic fever? heart or vascular problems? (please specify Yes No
4 19. Have you ever had any medical test for your heart (i.e. EKG, echocardiogram)? Yes (if so specify test and reason below) No Test Reason 20. Have you ever had: Bronchitis? Tuberculosis? Asthma? Wheezing that starts during or just after exercise? Pneumothorax (collapsed lung)? 21. Have you ever had a concussion (injury to the head) with or without loss of consciousness? Yes (if so, please complete the table below) No How many times? 1X 2X 3X 4X 5X More than 5 times 22. Have you ever been knocked unconscious? Yes (if so, please complete the table below) No How many times? 1X 2X 3X 4X 5X More than 5 times What is the longest time that you have been unconscious due to a head injury? A few seconds up to 5 minutes 6-15 minutes longer than Have you ever had any long term problems due to a head injury (e.g. memory loss, (headaches) 24. Have you ever had numbness, tingling, or weakness in your: Shoulders/arms hands Buttocks? Legs/feet?
5 25. Have you ever had a burner or stinger (an injury causing a sudden burning pain and numbness down the arm and/or hand)? 26. Have you ever had a seizure? 27. Do you experience migraine headaches? 28. Have you ever had a serious eye injury? Yes (if so, please specify below) No 29. Do you wear glasses or contact lenses? Yes (if so, please complete the table below) No Do you wear glasses or contacts when you train or compete? Have you had your eyes checked in the past 12 months? 30. Are you legally blind in either of your eyes? WOMEN ONLY, MEN SKIP TO QUESTION # At what age did your menstrual periods start? years of age. 32. When was your most recent menstrual period? 1 month ago 1-3 months ago 4-6 months ago 6 months ago 33. In the past 12 months: Have you had trouble with menstrual bleeding? Have you had bleeding between periods? Have you had menstrual cramps or pain which affected your school or athletic performance? Have you had any unusual discharge from your vagina? How many periods have you had? >12 What was the longest time between periods? <1 month 1-3 mo 4-6 mo >6 mo On the average how long has each period lasted? 1-5 days 6-10d d >15d 34. Are you presently taking any female hormones (estrogen, progesterone, birth control pills) for the purpose of regulating your periods?
6 35. Have you ever had a pelvic exam/pap smear? Yes (if so, please complete the table below) No When were your last pelvic exam/ Pap smear? 1 year 1-3 years 3 years Has your pelvic exam/pap smear ever been abnormal? MEN ONLY, WOMEN SKIP TO QUESTION# Were you born with two normal testes? 37. Have you ever had surgery to remove or repair a testicle(s)? ==================================================================== ORTHOPAEDIC HISTORY 38. In the past 12 months have you seen a physician, athletic trainer or other health care professional for a new or ongoing injury? Yes ( if so, please complete the table below) No injury (is): has the injury healed completely 39. Do you presently use for practice or competition: A brace, splint, or sleeve? Orthotics (shoe inserts)? Have you ever had or do you currently have an injury or problem of the following: 40. Neck: Place an X if the condition exits at present. Disc disease Facet disorder Whiplash specify
7 41. Spine/Back: Place an X if the condition exists at present: Congenital deformity or birth Disc disease defect Facet disorder Sacroiliac disorder Back pain Scoliosis Back stiffness Spondyloysis Spondylolisthesis 42. Shoulder/Clavicle: Place an X if condition exists at present. Subluxation Acromioclavicular (AC) joint Rotator cuff tendonitis/impingement Instability 43. Upper arm/ forearm: Place an X if condition exists at present: Muscle injury Tendon injury 44. Elbow: Place an X if condition exists at present: Ligament injury Tennis (golfer s) elbow 45. Hand/Wrist/ Fingers: Place an X if condition exists at present: Ligament injury Tendon injury or tendonitis
8 46. Pelvis/Hip Place an X if condition exists at present: Tendonitis Contusion/hip pointers Groin strain 47. Thigh: Place an X if condition exists at present: Tendonitis Hamstring strain/injury Quadriceps strain/injury Severe contusion 48. Knee: Place an X if condition exists at present: Meniscal injury Locking PCL tear of knee or patella (knee cap) ACL tear Swelling Iliotibial band syndrome Unexplained pain Collateral ligament injury Meniscal surgery Tendonitis ACL surgery injury Pain around knee cap, (patello surgery femoral pain Sensation of catching, instability, giving away 49. Lower Leg: Place an X if condition exists at present: Shin splints Muscle strain Compartment syndrome 50. Ankle: Place an X if condition exists at present: Bone chip in joint Sprain Tendonitis
9 Instability 51. Foot / Toes: Place an X if condition exists at present: Traumatic Fracture Flat arches of feet Sprain Tendonitis / tendon injury Bone spur Plantar fascitis 52. In the past 10 years, have you been treated for a serious injury(s) not mentioned in the above? Yes (if so, please specify below) No injury(s) Month Year 53. In the past 12 months, what is the total number of days of training and competition that you have been unable to participate in due to any injury? (Pick the most appropriate category for each injury you have had. List each injury only once). Never > 14 injury site had days days days or type Shin splints (s) (s) Tendonitis/ tendon injury(s) Sprain Pulled muscle(s) Back problem(s) Ligament injury or tear Joint injury(s) or pain injury injury injury
10 54. Have you ever had a cortisone injection into a tendon, bursa, or joint for an injury or pain? Yes (if so, please specify below) No injury (s): Date Month Year FAMILY HISTORY 55. For each full-blood relative listed, please indicate if they have a history of the following (do not include adoptive, step, or foster relatives). (Place an X in all boxes that apply; mark no history in family if appropriate or if family history unknown): High blood pressure Heart attack heart abnormalities High blood cholesterol Diabetes Arthritis Bleeding disorder Marfan syndrome Kidney disease Mental illness Sickle cell anemia Epilepsy Cancer No family history Mother/Father Brother/Sister Grandparent 56. Have any of your full-blood relatives (father/mother, brother/sister, grandparent) died suddenly before the age of fifty, other than due to trauma? Yes (if known, please specify reason below) No 57. Please indicate your ethnic orgin (place an X in all that apply). Native American/Alaska Native Asian Pacific Islander Black,/African American Hispanic/Latino/Chicano White (non-hispanic, specify: Don t know
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