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Medical history questionnaire

Section: Athletic Training Services

Subject: Medical History Questionnaire
Purpose: To define the form to be used for the Medical History of an SBU student-athlete. Policy: The following form must be filled out prior to any student-athlete participation in any practice or game at SBU. MEDICAL HISTORY QUESTIONNAIRE
TODAY’S DATE_________________ Name:______________________________________________________ Social Security Number:___________________________________________ Sport:___________________________________ Parent or Guardian Name:__________________________________________________________________________________________________________ Parent or Guardian Home Address:_________________________________________________________ __________________________________________________________ Parent/Guardian Home Phone:____________________________________ Parent/Guardian Work Phone:_______________________________________ EMERGENCY CONTACT INFORMATION Name:_______________________________________________ Relationship:_______________________ Phone Number________________________ Address:________________________________________________________________________________________________________________________
PERMISSION TO TREAT: I give permission for SBU Team Physicians, SBU Athletic Training Services and CMH Sports Medicine to perform
evaluations and treatment for injuries occurred in my sport. I understand that medical expenses incurred for medical care that is not from an injury
incurred in my sport are my responsibility.

Signed:_______________________________________________
Parent/Guardian Signature:________________________________________
This is a confidential record of your medical history. Information contained here will not be released to anyone except when you
have authorized us to do so.
Please circle answers and provide information/details with any “YES” answers. Attach documents or medical records where
necessary.
____________________________________________ ____________________________________________ 1.__________________________________________ 2.__________________________________________ 3.__________________________________________ 4.__________________________________________ Weight: Now_________ One year ago_______ Fractured, broken, cracked bones Yes / No CONTINUED ON BACK
List all sprains, strains, dislocations and fractures you’ve had in the last 5 years: ______________________________________________________________
List all surgeries/operations you’ve had in the last 5 years:________________________________________________________________________________
Have you ever been advised to have surgery which has not been done? Yes / No If yes, please give details:_______________________________________
Have you ever been advised by a physician to not participate in sports? Yes / No If yes, please give details:_________________________________________
Have you ever been hospitalized? Yes / No If yes, please give details:______________________________________________________________________

PLEASE REQUEST AND SEND/BRING PHYSICIAN’S REPORTS TO YOUR ATHLETIC TRAINER ON ANY SURGERY OR
HOSPITALIZATIONS YOU’VE HAD IN THE LAST 5 YEARS
DO YOU HAVE NOW, OR HAVE YOU HAD ANY OF THE FOLLOWING IN THE LAST YEAR?
Frequent or severe headache

Recurrent back pain
IMMUNIZATIONS / Date
Fainting spells
Recurrent neck pain
Tetanus_________________
Migraines
Joint pains
Diptheria________________
Blurred vision
Swelling of any joints
Polio____________________
Double vision
Osgood Schlatter’s
Measles (Rubella)_________
Spots before eyes
Patellar chondromalacia
Mumps or MMR___________
Infected eyes
Tingling/weakness of hands/feet
Smallpox________________
Pain behind eyes
Muscle spasms/cramps
Chicken pox______________
Do you wear glasses
Tiredness without apparent reason
Tuberculosis_____________
If yes, when were they last checked?________
Easy bruising
Hepatitis_________________
Do you wear contacts
Inability to stand heat
Inability to stand cold
Any skin rash
During competition
Heat exhaustion
Earaches
Heat stroke
Discharge from ears
Pain in arm(s)
Ringing in ears
Night sweats
Decrease in hearing
Chronic or frequent coughs
Hearing problems
Chronic or frequent cough when
Recurrent nosebleeds
laying down
Recurrent head colds
Wake up at night short of breath
Sinus trouble
Purple lips or fingers
Hay fever
Palpations or fluttering heart beat
Strange, persistent odors
High or low blood pressure
Strange taste or loss of taste
Swelling of hands, feet or ankles
Persistent hoarseness
Dizziness with activity
Difficulty swallowing
Leg cramps on waking or at night
Enlarged glands
Recurrent stomach pain/heartburn
Recurrent sore throats
Nausea or vomiting
Recurrent sores in mouth
Abdominal cramps
Soreness or bleeding of gums
Dark black bowel movement
Chest pain
Pain on urinating
Coughed up blood
Any blood with urinating
Wear orthotics

CHECK ANY MEDICATIONS/SUPPLEMENTS YOU ARE TAKING:
Accutane_________

I certify that all answers to the above statements are correct and true. I understand that Southwest Babtist University is not responsible for any
previous medical conditions I might have.
Signed:________________________________________ Date:_______________

Witness:___________________________________________
Student/Athlete
Certified Athletic Trainer

Source: http://www.sbuniv.edu/cosm/at/P08.41.pdf

Ojhas: 2012-4-15

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