P a g e 1 INITIAL MEDICAL PACKET Name: Sport: Date: Last First Middle SSN: - - DOB: / / Age: Cell Phone: ( ) - Home Phone: ( ) - Family Physician: Phone: ( ) - Emergency contact: Name: Phone: ( ) - Relationship: 1. SPECIFIC MEDICAL HISTORY *Please circle either yes or no. *Please explain in more detail if your answer is yes. 1. Have you ever been hospitalized? (Include reason and list of facility/location) 2. Have you ever had surgery? (Include reason and list of facility/location) 3. Do you have any allergies (Medication, Food, etc.)? 4. Do you have any seasonal allergies (bees, pollen, etc) that require medical treatment? If yes, please identify: List of treatment: 5. Have you lost any paired organs (Eye, Kidney, Testicle, etc)? Month/YR 2. PRESCRIPTION, SUPPLEMENTS, AND OTHER AGENTS Month/YR 1. Are you currently taking any prescription medication? Prescribed by: 2. Are you currently taking any prescription medication for the treatment of ADD/ADHD? _ (Adderall, Ritalin, Concerta etc.) Prescribed by: _ 3. Are you currently taking any non-prescription medication? If yes please list: Prescribed by: 4. Are you currently taking any supplements (protein, vitamin, calcium, diet pills, etc.)? If yes please list: 3. HEART 1. Have you ever been dizzy or passed out during or after exercise? 2. Have you ever experienced chest pains during or after exercise? 3. Have you ever experienced a racing heart rate or skipped heartbeats during exercise? 4. Has anyone in your family died of a heart problem or sudden death before age 40? 5. Has a physician diagnosed anyone in your family with abnormally thickened heart? 6. Has a physician diagnosed you or anyone in your family with Marfan Syndrome? Month/YR
P a g e 2 7. Have you ever had any testing done on your heart? (Example: EKG, Stress Testing, Echocardiogram, etc.) 8. Has a physician denied/restricted your participation in athletics for any heart problem? *IF ANY CARDIAC/HEART TESTING HAS BEEN PERFORMED, YOU MUST SEND COPIES OF ALL 4. ENVIRONMENTAL CONDITION Month/YR 1. Have you ever had any exercise-related dehydration, heat cramps, or heat stroke? 2. Have you ever been dizzy or passed out in the heat? 5. PULMONARY FUNCTION Month/YR 1. Do you have trouble breathing or do you cough or wheeze during or after activity? 2. Have you ever been diagnosed with asthma? 3. Do you use an inhaler? 6. HEAD & NECK Month/YR 1. Have you ever had a head/neck injury that has interrupted your athletic activity? Y Yes N or No If yes, please explain and how long were you in inactive: 2. Have you ever been hospitalized for a head/neck injury? If yes please explain and how long were you in inactive: 3. Have you ever had head injury in your life? 4. Have you ever had concussion in your life? 5. Have you ever had loss of consciousness? 6. Have you ever had loss of memory? 7. Do you get headaches (NOT related to previous concussion or head injury)? 8. Have you ever had eyes pain or discomfort with these headaches? 9. Have you ever had stomachache with these headaches? 10. Have you ever had headaches which limit your activities in any way? 11. Have you ever had any diagnostic testing for a head/neck injury? (X-ray, MRI, CT Scan, ect.) 12. Does anyone in your family suffer from migraine headaches? 13. Have you ever had a seizure? *IF ANY DIAGNOSED TESTING HAS BEEN PERFORMED, PLEASE SEND COPIES OF ALL TESTING AND PHYSICIAN REPORTS TO THE BC SPORTS MEDICINE STAFF. 7. EYE, NOSE, & DENTAL 1. Have you ever fractured your nose? 2. Have you had any problem with your eyes or vision? 3. Do you wear glasses, contacts or protective eyewear? 4. When was the last time eye exam? 5. Have you had any significant dental procedures? (Including braces. Plates, Caps, etc.)
P a g e 3 8. SKIN CONDITION Month/YR 1. Do you have any current skin problems (warts, acne, etc.)? 2. Have you ever been tested for MRSA? Diagnoses by: 3. Do you take any medication for a skin condition? Prescribed by: 9. DISEASES & ILLNESSES 1. Have you ever been tested for sickle cell trait? Diagnoses by: 2. Do you have a record of your sickle cell testing? 3. Have you included these records with your medical information? 4. Have you ever had the following illnesses or childhood diseases? Measles: Mumps: Chicken Pox: Rheumatic Fever: Appendicitis: Abdominal Problem: Mononucleosis: Asthma: *IF ANY DIAGNOSED TESTING HAS BEEN PERFORMED, PLEASE SEND COPIES OF ALL TESTING AND PHYSICIAN REPORTS TO THE BC SPORTS MEDICINE STAFF. 10. FAMILY MEDICAL HISTORY Have you or any member of your family had the following medical problems? Yourself Family Member Relation to family member ADD/ADHD Anemia Diabetes Epilepsy Headaches Heart Disease/Attack Heart Murmur Hernia Hepatitis High Blood Pressure Kidney/Bladder Infection or Stones Liver/Gall Bladder Disease Marfan s Syndrome Mononucleosis Mumps Sickle Cell Trait Tuberculosis Valley Fever Viral Infection (within last month) Missing any paired organ (kidney, etc) Other: 9. SUBSTANCE USE Do you smoke or use tobacco products? If yes, explain how often: 10. FEMALE STUDENT-ATHLETE ONLY 1. At what age did you have your first menstrual cycle? 2. How many days does your cycle last? How many days between cycles?
P a g e 4 3. How many periods have you had in the past 12 months? 4. Have you ever had menstrual problems? (Irregular, heavy bleeding, stopping cycle, etc.) (cycles shorter than 21 days or with more than 35 days between cycles) 5. Do you or have you taken Birth Control or Hormones? If yes, please explain? 6. Has a physician ever told you that you had anemia (low hematocrit or iron)? 7. Are you now or have you ever been pregnant? If yes, please explain with dates: 14. MALE STUDENT-ATHLETE ONLY Month/YR 1. Have you ever been diagnosed with a hernia? 2. Have you ever had a serious injury to your gentiles? 15. WEIGHT CONTROL 1. Have you ever tried to control your weight? By: Dieting/Fasting? Diet Pills? Diuretics (water pills)? Laxatives? Vomiting? Excessive Exercise? 2. Have you ever taken any supplements to help for your weight control or your performance? Yes Y or NoN *IF ANY DIAGNOSED TESTING HAS BEEN PERFORMED, PLEASE SEND COPIES OF ALL TESTING AND PHYSICIAN REPORTS TO THE BC SPORTS MEDICINE STAFF. I/We hereby certify that the above questions are answered to the best of my knowledge. It is understand that this information will be used by Central Christian College of Kansas Team Physicians and Certified Athletic Trainers to determine participation status for intercollegiate athletics. Athlete s Signature Date If under 18, Parent/Guardian Signature Date
P a g e 6 Student-Athlete Information Sheet Athlete s Name: Date: Last First MI Date of Birth: / / Age: SSN: / / Sex: M or F Athlete s Phone Number: ( ) - Email: Marital Status: Single Married Widowed _ Divorced Legally Separated Home Address: City: State: Zip: Year in School: FR SO JR SR List Participating Sports: Positions: Insurance Company: Phone #: Group Number: Primary Card Holder: Policy Number: PCH Phone#: Mother s Name: Phone #: Father s Name: Phone #: EMERGENCY CONTACT INFORMATION Name: Phone: Relationship: Name: Phone: Relationship: