Sports Physical Questionnaire

Name

Age:

Date:

School:

Grade:

Sports:

Explain “YES” answers below. Circle questions you don’t know the answers to.

1. Have you had a medical illness or injury since your last check up or sports physical?

Yes No

2. Have you ever been hospitalized overnight?

Yes No

3. Are you currently taking any prescription or non-prescription medications or inhalers?

Yes No

4. Have you ever taken any supplements or vitamins to help you gain or lose weight or to improve your performance?

Yes No

5. Do you have any allergies (pollen, medicine, food, stinging insects)?

Yes No

6. Have you ever had a rash or hives develop during or after exercise?

Yes No

7. Have you ever passed out during or after exercise?

Yes No

8. Have you ever been dizzy during or after exercise?

Yes No

9. Have you ever had chest pain during or after exercise?

Yes No

10. Do you get tired more quickly than your friends do during exercise?

Yes No

11. Have you ever had a racing of your heart or skipped heartbeats?

Yes No

12. Have you had high blood pressure or high cholesterol?

Yes No

13. Have you ever been told you have a heart murmur?

Yes No

14. Has any family member or relative died of heart problems or of sudden death before age 50?

Yes No

15. Have you ever had a severe viral infection within the last month (myocarditis, mononucleosis)?

Yes No

16. Has a physician ever denied or restricted your participation in sports for any heart problems?

Yes No

17. Do you have any current skin problems (itching, rashes, acne, warts, fungus, or blisters)?

Yes No

18. Have you ever had a head injury or concussion?

Yes No

19. Have you ever been knocked out, become unconscious, or lost your memory?

Yes No

20. Have you ever had a seizure?

Yes No

21. Do you have frequent or severe headaches?

Yes No

22. Have you ever had numbness or tingling in your arms, hands legs, or feet?

Yes No

23. Have you ever had a stinger, burner, or pinched nerve?

Yes No

24. Have you ever become ill from exercising in the heat?

Yes No

25. Do you cough, wheeze, or have trouble breathing?

Yes No

26. Do you have asthma?

Yes No

27. Do you have seasonal allergies that require medical treatment?

Yes No

28. Do you use any special protective or corrective equipment or devices that aren’t usually used for your sport or position (knee brace, special neck roll, foot orthotics, retainer, hearing aid)?

Yes No

29. Have you had problems with your eyes or vision?

Yes No

30. Do you wear glasses, contacts, or protective eyewear?

Yes No

31. Have you ever had a sprain, strain, or swelling after injury?

Yes No

32. Have you broken or fractured any bones or dislocated any joints?

Yes No

33. Have you had any other problems with pain or swelling in muscles, tendons, bones or joints?

Yes No

If yes, explain:

34. Do you want to weigh more or less than you do know?

Yes No

35. Do you lose weight regularly to meet weight requirements for your sport?

Yes No

36. Do you feel stressed out?

Yes No

Female only

When was your first menstrual period?

When was your last menstrual period?

How much time do you usually have from the start of one period to the start of the next?

How may periods have you had in the last year?

What was the longest time between periods in the last year?

Explain “YES” answers here

I hereby state that, to the best of my knowledge, the answers to the above questions are complete and correct.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of athlete:

Signature of parent/guardian:

Date:

Your information will be encrypted.