Physical Activity Form

Patient's Name:

Age

Date

Please list all sports you may participate in over the next 12 months

Have you ever passed out or nearly passed out DURING OR RIGHT AFTER EXERCISE?

Yes No

Do you ever get light-headed DURING EXERCISE?

Yes No

Does your heart ever flutter or skip beats DURING EXERCISE?

Yes No

Do you ever get very short of breath (more than your friends, or so much that you can’t catch your breath) DURING EXERCISE?

Yes No

Have you ever had chest pain, chest tightness, or pressure in your chest DURING EXERCISE?

Yes No

Has a doctor ever told you that you have any heart problems or recommended a test for your heart like an ECG/electrocardiogram or echocardiogram?

Yes No

Are there any family members who died of heart problems before age 35?

Yes No

Are there any family members who had unexpected, unexplained death before age 35 (include SIDS, car accident, drowning, others)

Yes No

Has anyone in your family had a pacemaker or implantable defibrillator before the age of 35?

Yes No

IN THE PAST YEAR have you had any injuries?

Yes No

If yes, please list

IN THE PAST YEAR have you been hospitalized or had surgery?

Yes No

If yes, please list

Have you ever had a seizure?

Yes No

If yes, when?

Have you ever had a concussion?

Yes No

If yes, when?

Do you have asthma?

Yes No

Do you take any medications?

Yes No

If yes, please list

Do you have any allergies (i.e. medicines, foods, wasps/bees)?

Yes No

If yes, please list

FOR GIRLS

At what age did you have your first period?

How often do you usually have a period?

How long do your periods usually last?

If your periods are irregular, IN THE LAST YEAR what is the longest time you have gone between periods?

FOR BOYS:

Do you have groin or testicle pain or a painful bulge or hernia in the groin area?

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SIGNATURE OF PATIENT OR PARENT

Date

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