Jones Co. Jr. College Sports Medicine Medical History Questionairre DEMOGRAPHIC INFORMATION Full Name: Social Security #: - - Date of Birth: Sport: Year in School: Home Phone #: Cell Phone #: Parent/Guardian Name(s): Permanent Address: City: State: Zip: FAMILY HISTORY Has anyone in your immediate family ever been diagnosed with any of the following? Circle Yes or No Heart Disease Yes No Diabetes Yes No High Blood Pressure Yes No Cancer Yes No Stroke Yes No Tuberculosis Yes No Sudden Death (before age 50) Yes No Asthma Yes No Epilepsy Yes No Gout Yes No Migraine Headaches Yes No Mental Illness Yes No Eating Disorder Yes No Sickle Cell Anemia Yes No Marfan s Syndrome Yes No Drug/Alcohol Abuse Yes No PERSONAL HISTORY Allergies List any other allergies that you may have: Medications Do you currently take any prescription medications? Yes No If yes, please indicate which medication(s) you take and for what reason: Do you currently take any over-the-counter medications? Yes No If yes, please indicate which medication(s) you take and for what reason: Do you take any supplements (i.e., vitamins, creatine, protein, weight gainer)? Yes No If yes, please indicate which supplements or vitamins:
General Medical Have you ever been diagnosed with any of the following medical conditions? (Circle Yes or No) Mononucleosis Yes No Diabetes Yes No Anemia Yes No Rheumatic Fever Yes No Ulcers Yes No Hernia Yes No Sickle Cell Anemia Yes No Marfan s Syndrome Yes No Migraine Headaches Yes No Depression Yes No Kidney Disease Yes No Tuberculosis Yes No Hepatitis Yes No Crohn s Disease Yes No Chicken Pox Yes No Jaundice Yes No Measles Yes No High Blood Pressure Yes No Pneumonia Yes No Heart Palpitation Yes No Mumps Yes No Appendectomy Yes No Heat Stroke Yes No Scarlet Fever Yes No Chest Pain Yes No Epilepsy/Seizures Yes No Please explain all Yes answers Please list any other medical illness or condition that you may have had that is not listed in this questionnaire: Have you ever suffered from a Heat Illness (i.e., Heat Stress, Heat Exhaustion, and Heat Cramps)? Yes No Have you ever suffered from Muscle Cramps? Yes No Have you ever had shortness of breath or unusual fatigue with exercise? Yes No Please explain all Yes answers, including when it occurred: Has anyone in your family suffered a premature (50 years or younger) death or significant disability from a heart condition? Yes No Do you know of any close relatives with heart conditions? Yes No Have you ever been told that you have a heart condition? Yes No Have you ever passed out during or after any exercise session? Yes No Have you ever been dizzy during or after any exercise session? Yes No Have you ever had chest pain or discomfort during or after any exercise session? Yes No Have you ever been diagnosed with high blood pressure? Yes No Have you ever been diagnosed with racing of your heart or skipping heartbeats? Yes No Have you ever had chest pain while exercising? Yes No Have you ever been told you have a heart murmur? Yes No Have you ever had high cholesterol? Yes No Have you ever missed any practices or games due to any of the above conditions? Yes No Have you ever undergone any testing on your heart? Yes No Have you ever seen a Doctor for any of the above conditions? Yes No Please explain all Yes answers, including when it occurred: Do you have a history of Asthma? Yes No If yes, do you currently use an inhaler? Yes No Please list the medication used and how often: If yes, please provide dates: Are you missing or have impaired function of any paired organ (i.e., kidney)? Yes No Have you ever had any unusual or internal bleeding? Yes No If yes, please explain: Have you ever been hospitalized for any reason? Yes No Have you ever had surgery on any body part? Yes No
Are you currently under a Doctor s care for any reason? Yes No Please list the following information, if applicable: Do you have a family doctor? Yes No Name of Family Doctor: Phone #: Address: City: State: Zip: Vision History Do you wear glasses or contacts? Yes No Which? Do you wear them during competition? Yes No What is the date of your last eye exam? Dental History Do you currently suffer from any dental problems? Yes No Do you wear a mouthpiece or other dental protective device other than equipment required by your sport? Yes No Orthopedic/Injury History Do you have a family orthopedic doctor? Yes No Name of Orthopedic Doctor: Phone #: Address: City: State: Zip: Have you ever had surgery on any body part for an injury suffered during sports participation? Yes No Do you have a pin, screw, or plate in any part of your body? Yes No If yes, please explain, including dates: Have you ever had an x-ray, CT Scan, or MRI Scan taken on any body part, including your head, neck, and spine? Yes No If yes, please explain, including dates: Do you require any special taping or protective devices, such as a brace, for sports participation? Yes No Please indicate any injuries to the following: Head: Skull Fracture Yes No Internal bleeding of the skull Yes No Concussion Yes No Knocked Unconscious Yes No Other: Please explain all Yes answers, including when they occurred: Were you treated by a doctor following these head injuries? Yes No What doctor were you treated by? How many games and/or practices did you miss due any head injuries? Neck: Fracture Yes No Burners/Stingers Yes No Pinched Nerve Yes No Numbness/Tingling/Burning Yes No Other:
Back: Scoliosis Yes No Spina Bifida Yes No Disc Injury Yes No Degenerative Disc Yes No Muscular Injury Yes No Numbness/Tingling/Burning Yes No Other: Shoulder: Dislocation Yes No Subluxation Yes No Separation Yes No Rotator Cuff Injury Yes No SLAP Lesion Yes No Thoracic Outlet Syndrome Yes No Fracture Yes No Other: Elbow/Wrist: Fracture Yes No Sprain Yes No Dislocation Yes No Other: Hip: Dislocation Yes No Hip Pointer Yes No Degenerative Joint Yes No Other: Knee: Osgood s Schlatter Disease Yes No Ligament Injury Yes No Cartilage Injury Yes No Patella (knee cap) Injury Yes No Subluxation Yes No Dislocation Yes No Muscular (Hamstring, Quad) Yes No Other: Foot/Ankle: Sprain Yes No Dislocation Yes No Fracture Yes No Achilles Tendon Injury Yes No Shin Splints Yes No Plantar Fasciitis Yes No Flat Feet Yes No High Arches Yes No Other: Please List any other injuries not listed above:
Sickle Cell Trait Do you have a parent with sickle cell trait or sickle cell anemia? Yes No Have you been told you have sickle cell trait? Yes No Have you been tested for sickle cell trait? Yes No If you do not know if you have been tested or you have not been tested for sickle cell trait, testing is recommended. Please check one of the following options and sign and date below. I, would like to be tested for sickle cell trait. Print athlete s name I, do not wish to be tested for sickle cell trait. Print athlete s name PHYSICAL SCREENING WAIVER FORM To the best of my knowledge, I have given true and complete information, and hereby grant my permission for the athletic health screening. We acknowledge this examination is for screening purposes only and does not take the place of your normal complete periodic exam/annual well-child exam. This screening exam is for clearing athletes to participate in sports and does not represent the total health of the child. This exam is not meant to be a comprehensive physical exam. The passing of the physical examination does not necessarily mean that the child is qualified to engage in athletics, but only that the physician did not find a medical reason to disqualify the child at the time of the examination. The normal history and examination does not mean that a potentially life threatening health problem is not present. There are no studies that have shown that these screening exam requirements reduce sudden cardiac death. We agree to allow Hattiesburg Clinic to release a copy of this screening to the athlete s school, which is required for participation. This waiver, executed by Hattiesburg Clinic, PA and the athlete is executed in compli9ance with Mississippi law, which provides a physician voluntarily provides needed medical or health services to any program at an accredited school in the state without expectation of payment the physician will be immune from any liability for any civil action arising out of the provision of those medical and/or health care services which were provided in good faith on a charitable basis. Such immunity does not extend to act of willful or gross negligence. Print Name Student- Athlete Signature Date