UWSP Medical History Form

Transcription

1 UWSP Medical History Form Student: Please complete the first 6 pages prior to your appointment with your medical provider. The medical provider must sign off on the medical history form. Student Information Name Date Sport School Address Street City State Zip Age Date of Birth SEX Male Female Phone (Cell) Emergency Notification Information Emergency Contact Relationship Address Street City State Zip Phone (Home) (Work) (Cell) Family History Among your blood relatives, is there a history of the following: Alcoholism or abuse of alcohol/other drugs Allergies Emotional, mental or psychiatric problems Recurrent severe headaches Hypertension (high blood pressure) Heart disease Stroke Thyroid disorders Cancer Diabetes Tuberculosis Other serious illness Yes No Who/When 1

2 Medical History Please answer the following questions about your medical history. If you answer YES to any question, provide the date(s) and provide explanation. General Date If yes, please explain Are you currently ill in any way?. Do you currently have an injury which is not completely healed?. Have you ever been hospitalized?. Have you ever had surgery?. Are you currently taking any medication? (include ADHD, prescription meds, supplements, over the counter meds or birth control.)attach additional sheet if necessary. This information is also needed for drug testing purposes. Are you currently taking any herbal or dietary supplements? Do you have any allergies? (medications, bee stings, food, etc.) Have you been diagnosed with any mental or emotional illness? Are you currently taking any prescribed medication for this? Please list: If taking medication for ADHD, please include the following with your physical forms. a. Record of the student-athlete s evaluation. b. Statement of the Diagnosis, including when it was confirmed. c. History of ADHD treatment (previous/ongoing). d. Copy of the most recent prescription (as documented by the prescribing physician). Name of Medication: If yes, what If YES, please explain: Have you ever been under the care of a psychiatrist or psychologist? Have you been diagnosed with Diabetes? What type of Diabetes? Do you use an insulin pump? If YES, please provide dates: Type I Type II List any precautions that you take. 2

3 Have you had recurrent severe headaches? How often? Do you have a history of Migraines? How often? Do you have any skin problems? Have you had rheumatic fever? Have you had tuberculosis? Have you had/have hepatitis? Do you have (or had) any type of bleeding disorder? Describe: Describe: Do you use tobacco? Type/How much?/how often? Do you drink alcohol? How much per day? Per week? Any other illicit drug use? Amount: How often? Have you been tested for sickle cell trait? Positive Negative Has your doctor ever said you have a high lipids (cholesterol and triglycerides) or fats in your blood? Any other serious illness not discussed above? Cardiac Date If yes, please explain Has your doctor ever said you have heart problems? Have you ever had chest pain and/or shortness of breath during exercise? Have you ever felt dizzy, light-headed and/or passed out during or after exercise/practice? Have you ever had an electrocardiogram (EKG) of your heart? Do you have high blood pressure? Have you ever been told you have a heart murmur? 3

4 Have you ever had racing of your heart or skipped heartbeats? Has any family member been treated for heart related problems? Has any family member died of heart problems or sudden death before the age of 50? If YES, please explain: If YES, please explain: Does anyone in your family have any an inherited/diagnosed heart condition? i.e. hypertrophic cardiomyopathy, Marfan syndrome, arrthymogenic right ventricular cardiomyopathy, long QT syndrome, Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia? Does anyone in your family have a heart problem, pacemaker or implanted defibrillator? Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? Neurological Date If yes, please explain Have you ever had a head injury/concussion? If so, please list number of concussions and date. Time Loss?/Loss of consciousness? Have you ever been knocked out or unconscious? Have you ever had a seizure/fit/spell/epilepsy? Have you ever had a stinger, burner, or pinched nerve? Pulmonary Date If yes, please explain Do you have a blood relative in your immediate family (parent, brother, sister) who has had a heart attack or coronary artery by-pass before the age of 55? 4

5 Do you have any history of asthma or exercise induced asthma? Do you have trouble breathing or do you cough during or after activity? If yes, please bring a second inhaler. Orthopedic Date If yes, please explain (R vs. L, severity, etc.) Have you ever strained/sprained, dislocated, fractured or had repeated swelling or other injuries to the following joints. Hip Knee Ankle Foot Shoulder Elbow Hand/wrist Neck Back Have you ever had a stress fracture or stress injury Have you ever been told you that you have low bone density (osteopenia or osteoporosis)? Do you have any history of serious back problems? Do you have any muscular or skeletal problems that would interfere with sports participation? Type of fx and number of fx s 5

6 Have you ever been diagnosed as anemic If yes, when Do you have any history of juvenile arthritis or connective tissue disorder? Do you have any unusual problems with: Date If yes, please explain Head, eyes, ears, nose, throat Heart Chest & lungs Stomach & intestines Kidney or bladder Hernia Do you have a loss or seriously impaired function of any organ (eye, kidney, lung, etc) Have you ever been diagnosed with an eating disorder? Are you concerned with your weight or diet? Are you trying to or has anyone recommended that you gain or lose weight? Are you on a special diet or do you avoid certain types of foods or food groups? FEMALES: How many periods have you had in the past 12 months? Does your menstrual cycle fluctuate with activity? How old were you when you had your first menstrual period? When was your most recent menstrual period? Are you currently taking any female hormones (estrogen, progesterone, birth control)? Age: Date: 6

7 MALES: Do you perform testicle exams? Females: Do you perform self-breast exams? MALES: Have you had/have any testicular problems? Immunizations Tetanus/diphtheria or TdaP Date of most recent booster Have you been advised to restrict activity in the last five years? Yes No Explain: Are you aware of any reason you should not participate in all athletics? Yes No I, hereby give permission to undergo medical treatment for any injury/illness that I sustain or acquire while engaged in intercollegiate athletics at the University of Wisconsin Stevens Point (UWSP). I understand that the medical personnel at UWSP, including certified athletic trainers, physicians, physician assistant, and physical therapists will only perform those procedures that are within their training, scope of professional practice, and the State of Wisconsin Practice Act to prevent, care for, and rehabilitate activity related injuries/illness. All information provided is accurate to the best of my knowledge and has not been falsified. Having understood the above statement, I freely sign this Permission to Provide Medical Treatment. Student-Athlete Signature Date Physician/NP/PA Signature Date **Please remember to upload into Front Rush once it is completed under the medical history** 7