THE UNIVERSITY OF ALABAMA SPORTS MEDICINE MEDICAL HISTORY

Transcription

1 THE UNIVERSITY OF ALABAMA SPORTS MEDICINE MEDICAL HISTORY / / Date Sport NAME: Last First Middle S.S. Number / / Date of Birth / / Age Sex- Male/ Female School Address Phone( ) Mother/Guardian Phone( ) Address Work Phone( ) City State Country Zip Father/Guardian Phone( ) (If same as above, Address Work Phone( ) City State Country Zip Emergency Contact other than Parents/Guardian (Non- Relative) Name Home Phone( ) Work Phone( ) Has Any Blood Relative Ever Had: (Please Check Either Yes or No) Sudden Death (Before Age 55) Blood Diseases (Sickle Cell, Leukemia) Diabetes Epilepsy Gout Heart Disease Hemophilia High Blood Pressure Mental Disorders Stroke Tuberculosis Drug and/or Alcohol Dependency COMMENTS Yes No Who?

2 IMMUNIZATION RECORD Condition Yes No Date of Injection(s) Tetanus/Diphtheria Measles, Mumps and Rubella (MMR) 1) 2) Measles and Rubella (MR) 1) 2) Influenza Hepatitis B 1) 2) 3) Meningitis Vaccine a) b) GENERAL MEDICAL HEALTH HISTORY Have you ever had the following medical conditions? If you do not know, mark NO. CONDITIONS YES NO CONDITIONS YES NO High Blood Pressure Skin Disease Rheumatic Fever Diabetes Rheumatic Heart Disease Sickle Cell Anemia/ Trait Pericarditis Anemia Any Heart Disease Abnormal Bruising Tumor, Growth, Cyst, Cancer Abnormal Bleeding Tendency Any ruptured organs Blood Disease Hepatitis Blood Clots Jaundice Kidney Disease Gout Kidney Stones Pleurisy Kidney Injury Pneumonia Blood in urine Polio Frequent Urinary Infections Bronchitis Hearing Defect/Loss Frequent Respiratory Infections Ear Infections Tuberculosis Muscular Disease Malaria Birth Defects Mumps Appendicitis Mononucleosis Stomach Ulcer (peptic) Red Measles Gastrointestinal Bleeding Rubella Constipation Chicken Pox Hemorrhoids Asthma Hernia Exercise Induced Asthma Arthritis Recurrent Sinusitis Joint Inflammation Sinus Infections Herpes (Oral) Nasal Polyps Herpes (Genital) Nose Fracture Sexually Transmitted Diseases Amnesia Car or Air Sickness Meningitis Nervous Breakdown Migraine Headaches Mental Disorder Seizure Disorder Drug Dependency Goiter, Thyroid Disease Depression Eating Disorder COMMENTS:

3 Do you CURRENTLY have any of the following symptoms or problems? Frequent Headaches Visual Changes Ringing in Ears Sore Throat Sinus Congestion Breathing Difficulty Recurring Coughing Chest Pain YES NO YES NO Abdominal Pain Muscle Cramps Frequent Nausea Frequent Vomiting Frequent Diarrhea Rectal Bleeding Unusual Fatigue Trouble Sleeping INTERNAL Were you born with a complete and functional set of paired organs? (Eyes, Ears, kidneys, Ovaries/ Testicles, Lungs): (Check) YES NO ; If not, which organs were involved? Have you ever had surgery to repair or remove any organ? (Hernia, Tonsils, Appendix, Spleen, etc.): CARDIAC Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? Have you ever passed out or nearly passed out during or after exercise? Do you get more tired or short of breath more quickly than your friends during exercise? Do you get lightheaded or feel more short of breath than expected during exercise? Does your heart ever race or skip beats (irregular beats) during exercise? Has a doctor ever told you that you have any heart problems? Check all that apply: High blood pressure A heart infection Heart murmur Kawasaki disease High cholesterol Other Has a doctor ever denied or restricted your participation in sports for any reason? Has a doctor ever ordered a test for your heart? (EKG, echocardiogram) Has any family member or relative died of heart problems or had unexpected death before age 50? Does anyone in your family have any of the following condtions? Hypertrophic cardiomyopathy Short QT syndrome Marfan syndrome Brugada syndrome Arrythmogenic cardiomyopathy Catecholaminergic polymorphic ventricular tachycardia Long QT syndrome 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? Have you ever had an unexplained seizure? YES NO COMMENTS:

4 VISION YES NO Have you ever been to an eye doctor? Date of last visit: Physician name: Do you wear glasses now? If yes, Reading only Rx: Rt. Distance only Lt. All the time Do you wear contact lenses? If yes, Soft lenses: Rx: Rt. Hard lenses: Lt. Do you have a second pair? Do you wear either to participate? Have you ever had an eye injury? Date of incident: Explain: Is your color vision normal? Have you ever worn a false eye? DENTAL Do you have now have or experienced any of the following? YES NO Comments Do you have a bridge? Have you ever fractured a tooth? Have you ever had a tooth knocked out? Do you wear a mouth protector? Do you wear orthodontic appliance? HEAT Have you ever experienced any of the following? Trouble with dehydration (Excessive loss of salt and water Heat stroke Heat Cramps (Due to fluid loss because of excessive heat) Heat Intolerance Have you ever had an I.V. due to dehydration or heat cramps? YES NO Are you allergic to? Aspirin Codeine Cortisone Sulfa Anti-Inflammatories Penicillin Hay Fever ALLERGIES YES NO YES NO Insect Bites/Stings Tetanus Antitoxin or Serums Nail Polish or Cosmetics Any Foods: Any other Drugs:

5 DRUG, FOOD SUPPLEMENTS AND MISCELLANOUS AGENTS Check the appropriate space according to YOUR use of the following items: Vitamins Diet Pills Sleeping Pills Laxatives Alcoholic Beverages Antihistamines Anti-Inflammatories Caffeine Tobacco Other Never Rarely Occasionally Frequently MENTAL HEALTH I often have trouble sleeping I wish I had more energy most days of the week I think about things over and over I feel anxious and nervous much of the time I often feel sad or depressed I struggle with being confident I don t feel hopeful about the future I have a hard time managing my emotions (frustration, anger, impatience) I have feelings of hurting myself or others Do you make yourself sick because you feel uncomfortably full? Do you worry that you have lost control over how much you eat? Have you recently lost more than 15 pounds in a three-month period? Do you believe yourself to be fat when others say you are thin? Would you say food dominates your life? List all medications that you currently take: YES NO

6 ORTHOPEDIC HISTORY QUESTIONNAIRE Please place a check in either the Yes or No box. If you do not know, check the No and indicate you do not know in the comment section. Have you ever injured or consulted a Physician about any injury to the HEAD Unconscious Dazed/ Dizzy Knocked Out Concussion Headaches YES NO DATE COMMENTS NECK Stretches Pinches Disc Injury Dislocation Burners/ Stingers YES NO DATE COMMENTS ***FOOTBALL ONLY*** Do you wear a neck roll? YES NO

7 CHEST WALL Fractured Collar Bone Fractured Ribs Sterno-Clavicular Joint Separation YES NO DATE COMMENTS LOWER BACK Nerve Pinches Disc Injury Referred Pain Pain Down Leg Numbness in Leg Weakness in Leg YES NO DATE COMMENTS HANDS/ FINGERS Dislocations Casted/ Splints Others:

8 Tendonitis Dislocations Casted Bursitis Dislocations Joint Locking Casted Tendonitis Swelling WRISTS ELBOWS Strain Calcium Deposit Casted Numbness in Fingers UPPER ARMS/ FOREARMS

9 A-C Separation Dislocations Partial Dislocation Shoulder Slips Out of Place Tendonitis Bursitis Pain w/ Overhead Activities Arm Goes Dead After Trauma SHOULDERS KNEES Strains Sprained Ligament Torn Cartilage Knee Cap Injury Knee Cap Dislocation Osgood Schlatter s Bursitis Swelling Locking Giving Away Sudden Weakness Shifting Wear Braces Casted Arthritis Chondromalacia Grinding Tendonitis Jumper s Knee Pain with Stairs Pain with Squats Arthrograms

10 FEET/ TOES Dislocation Turf Toe Casted/ Splinted ANKLES Dislocations Casted/ Splinted Instability Giving Out Weakness LOWER LEGS Shin Splints Torn Muscles Painful- Tight calf with activity Achilles Tendon Pain Stress Fracture

11 Quad Pulls Hamstring Pulls Torn Muscles Calcium Deposits THIGHS PELVIS/ HIPS Groin Pull Torn Muscles Dislocations Casted Have you had or do you have now any other medical problems or injuries not listed on this form? Do you have any medical or health problems that you are currently receiving medical treatment for? Is there any reason that you are not able to participate in athletics? Are there any additional health problems you would prefer to discuss privately with our team physician? If any of the first three questions above were answered with Yes, Please explain below: YES NO

12 List any special protective equipment you require or would like to have provided: The undersigned, herewith, A. Understands that he/she must refrain from practice or play during medical treatment until he/she is discharged from treatment or given a written permit by the attending physician to resume participation. B. Certifies that the answers to those questions are correct and true. C. Understands that his/her having passed the physician examination does not necessarily mean he/she is physically qualified to engage in athletics, but only that the examiner did not find a medical reason to disqualify him/her. D. Fully realizes The University of Alabama cannot be held responsible for any previous medical condition(s) that he/she might have. SIGNATURE OF ATHLETE: SIGNATURE OF LEGAL PARENT/GUARDIAN: PRINT NAME OF LEGAL PARENT/GUARDIAN: DATE:

13 THE UNIVERSITY OF ALABAMA SPORTS MEDICINE Female Athlete Survey Name: Sport: Age: Height: Weight: Desired Weight: The questions below, concern problems that are particular to female athletes. This form is intended to reveal a more complete medical picture of our female athletes, which will enable the Sports Medicine Department to provide the best health care. All answers to the questions will remain confidential to our medical staff. Answer all questions. 1. Are your periods regular? YES NO 2. Have you stopped having periods? YES NO 3. Are your periods painful? YES NO 4. Are your periods too heavy? YES NO 5. Are your periods light? YES NO 6. Do you smoke? YES NO 7. Do you drink heavily? YES NO 8. Have you ever been anemic? YES NO 9. Have you ever had a stress fracture? YES NO How many? Where? 10. Age at onset of menses: 11. Longest time between periods? months 12. Are you currently taking birth control pills or other hormones? YES NO 13. Are you taking vitamins? YES NO 14. Are you taking calcium supplements? YES NO 15. Are you taking iron supplements? YES NO 16. Have you had a pap smear (female exam)? YES NO Date of last Pap smear 17. Have you ever noticed a lump in your breast? YES NO

14 UNIVERSITY OF ALABAMA SPORT MEDICINE PRE PARTICIPATION PHYSICAL MEDICAL INFORMATION Name CWID Date Height _ Weight _ Pulse _ BP Vision R 20/ L 20/ Corrected: Y N Allergies: Medications: Medical History Changes Since Last Physical: _ GENERAL MEDICAL: EENT Heart Lungs Abdomen Genitalia Skin Normal Abnormal Findings Initials MUSCULOSKELETALINFORMATION: Neck Back Shoulder Elbow Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot Normal Abnormal Findings Initials PHYSICAL RESULTS: Cleared for full participation with no restrictions Cleared after completing evaluation for: Not Cleared due to Other Recommendations/Notes: Name of Physician (Please Print) Physician Signature Date