Player health history questionnaire form

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Bellarmine University
Department of Intercollegiate Athletics
Student-Athlete Health History Questionnaire Form The information contained in this medical history form will only be used by the Bellarmine University Sports Medicine Staff for purposes of determining if you pose a health threat/risk to yourself on the athletic field. Return this form (completed) to the Athletic Trainer’s office. This information will remain confidential at all times. Please print clearly in BLUE or BLACK INK only! Pencil is NOT acceptable. Initial any changes.

A. General Information
PERMANENT ADDRESS:
Home Phone (___ ) ____________________ Student’s Cell Phone (______)
Father’s Name ________________ Cell Phone (______) __________________ Mother’s Name_______________ Cell Phone (______) ______________________
B. Family Health History
C. Medical Questions
If you answer YES to any of the following questions that does not have a space to clarify the answer, you will need to provide an
explanation in the space provided on page 4 or, if necessary, on a separate sheet of paper. All answers will remain confidential.
CARDIOVASCULAR
1. Have you ever had chest pain and/or shortness of breath, dizziness, lightheadedness, or passed out during or after exercise/practice? IF YES, what was the cause? _______________________________________________________________________________________
2. Have you ever had the feeling of your heart racing or skipping beats during or after exercise/practice? 3. Do you get tired more quickly than your teammates/friends do during exercise/practice? 4. Have you ever been told that you have a heart murmur? 5. Has any family member or close relative had heart problems and/or died of sudden death before the age of 50? 6. Has a physician ever denied or restricted your participation in sports due to any heart/cardiovascular problems? 7. Have you ever had an electrocardiogram (EKG) and/or echocardiogram (ECHO) of your heart? IF YES, what were the reason(s) and the result(s)? ___________________________________________________________________________
8. Does anyone in your family have a history of high blood pressure? 9. Do you have a history of high blood pressure? 10. Does anyone in your family have a history of high cholesterol? ALLERGIES & ASTHMA
11. Have you ever been diagnosed with seasonal al ergies? 12. Are you presently taking or have you previously taken any allergy medications? IF YES, what medications were/are you taking?
13. Are you al ergic to and/or ever had an unfavorable/allergic reaction to any medications, food, insect bites, or bee stings? IF YES, what are you allergic to?
14. Have you ever been diagnosed with asthma and/or exercised-induced asthma? IF YES, then how many acute asthma attacks have you had in the past 12 months?
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15. Are you presently taking or have you previously taken any asthma medications or used an inhaler (e.g., Albuterol, Proventil, etc.)? IF YES, then how many times do you use your rescue inhaler during an average week?
HEAD & FACE
16. Have you ever suffered a head injury/concussion (no matter how minor)? IF YES, list date(s) & time(s) of practices and competitions missed
Every Day 1-2 Times/Week 1-2 Times/Month Front of Head Back of Head All Over Head 20. Do you have a history of migraine headaches? IF YES, are you currently taking any medication to treat your migraines? ___________________________________________________
22. Have you ever suffered an injury to your eye(s) and/or been advised that you have an eye disease? 23. Have you ever suffered from blurred vision, double vision, tunnel vision, and/or any other visual disturbances? 26. Do you require any special hearing devices/equipment? Type: 27. Have you ever suffered an injury to or had a problem with your ear(s), nose, and/or throat? 28. Have you ever suffered an injury to or had a problem with your mouth, jaw, and/or teeth? ORTHOPEDIC
29. Have you ever suffered an injury to or had a problem with your cervical spine and/or neck? 30. Have you ever had “burners”, “stingers”, or brachial plexus injuries? 31. Have you ever experienced numbness and/or tingling in your arms/fingers? 32. Have you ever suffered an injury to or had a problem with your shoulder/upper arm? 33. Have you ever suffered an injury to or had a problem with your elbow/forearm? 34. Have you ever suffered an injury to or had a problem with your wrist(s), hand(s), and/or finger(s)? 35. Have you ever suffered an injury to or had a problem with your spine/low back/sacroiliac joint? 36. Have you ever had numbness/tingling down one or both legs? 37. Have you ever suffered an injury to or had a problem with your hip or groin (including hernias and/or sports hernias)? 38. Have you ever suffered an injury to or had a problem with your thigh, hamstring, and/or quadriceps? 39. Have you ever suffered an injury to or had a problem with your knee and/or patella (kneecap)? 40. Have you ever suffered an injury to or had a problem with your ankle/lower leg/feet/toe(s)? 41. Have you ever or do you presently wear a brace? IF YES, please describe: _________________________________________________________________________________________
GENERAL MEDICAL
42. Have you ever suffered an injury to your rib/thorax/chest? 43. Have you ever been diagnosed with a problem with your stomach, abdomen, intestines, or rectum? 44. Have you ever suffered from severe or recurrent abdominal pain? 45. Have you ever had a stomach and/or duodenal ulcer? 46. Have you ever suffered from chronic or recurrent diarrhea? 47. Do you have only one of two paired, functioning organs (e.g., kidney, testicle, ovary)? 48. Have you ever been told that you have kidney disease? 49. Have you ever had gallbladder disease and/or a urinary problem? 50. Have you ever had Rubella (German Measles) and/or Rubella (Red Measles) or Chicken Pox? Please Circle which one. 51. Have you had a viral infection (i.e., mononucleosis, myocarditis) within the past six (6) months? 52. Have you ever been diagnosed with MRSA Staff Infection or been identified as an MRSA Carrier? 53. Have you ever been diagnosed with a communicable disease (STD; HIV; Hepatitis A, B, or C; Herpes Simplex; Syphilis; Tuberculosis)? 54. Do you have any skin problems that we should be aware of (e.g., itching, rashes, acne, warts, eczema, or fungus)? 55. Have you ever had a rash or hives develop during and/or after exercise? 56. Have you ever suffered from a heat-related il ness? IF YES, check al that apply:
57. Have you ever received intravenous fluids (IV) or been hospitalized for a heat-related problem? Bellarmine University Sports Medicine Page 3 of 5
58. Do you have a family history of diabetes? 59. Have you been diagnosed with diabetes? IF YES, do you daily monitor your blood sugar level?
60. Have you had your A1C level checked within the last three (3) months? 61. Have you had any hypoglycemic episodes (low blood sugar) within the last twelve (12) months? 62. Have you ever, to the best of your knowledge, been tested for Sickle Cell Anemia? 63. Does any member of your family, to the best of your knowledge, carry the Sickle Cel Trait/have Sickle Cell Anemia? 64. Have you ever been advised that you carry the Sickle Cell Trait/have Sickle Cell Anemia? 63. Have you ever been told by a physician to restrict your sports activity or not to participate in a sport? 64. Have you ever been under the care of a psychiatrist and/or psychologist? 68. Have you ever had seizures, convulsions, and/or epilepsy? 70. Do you have frequent ear infections or nosebleeds? 71. Have you had a tetanus booster within the past five (5) years? IF YES, when? _________________________
72. Have you ever received the Hepatitis B (HBV) vaccination series (all 3 shots)? IF YES, when? __________________
61. Have you ever had any injury or il ness other than those already noted? IF YES, please describe: __________________________________________________________________________________________
62. Do you have any ongoing or chronic il nesses? IF YES, please describe: __________________________________________________________________________________________
NUTRITION

73. Have you had a weight change (loss or gain) of greater than 10 pounds in the past year? 74. What is your ideal weight? __________________ 75. Are you a strict vegetarian, vegan, or do you have an atypical diet? IF YES, what type? YES
76. Would you like information on nutrition or healthy eating habits for athletes? 77. Do you regularly lose weight to participate in your sport? 78. Do you want to weigh more or less, than you presently do? 79. Have you had a history of anorexia, bulimia (forced vomiting), and/or any other eating disorders? IF YES, what product(s):
FOR FEMALES ONLY

82. At what age did you have your first menstrual period? 83. Have you had menstrual periods within the past 12 months? IF YES, how many?
When was your most recent menstrual period? What was the longest time between menstrual periods within the past year? 84. Do you have painful or heavy menstrual periods? 85. Do you take any medications during your menstrual periods? IF YES, what?
86. Do you take birth control? IF YES, what?
87. Have you ever had any problems with your breasts? 88. Have you had a pelvic examination within the last year?
FOR MALES ONLY

89. Have you ever had a testicular examination? IF YES, when was the most recent?
90. Have you ever been diagnosed with testicular cancer? Bellarmine University Sports Medicine Page 4 of 5
Answers:
If you have answered YES to any of the previous questions, please explain:
Prescription Medications:
Please list all prescription and over-the-counter medications you are currently taking or have taken in the past two (2) years and for what purpose.
MEDICATION
Supplements/Ergogenic Aids:
Please list all supplements/ergogenic aids that you are currently taking or have taken in the past two (2) years and for what purpose.
SUPPLEMENT
Catastrophic Injury Statement

The possibility of sustaining a catastrophic injury is inherent in any athletic activity. I understand that by
participating in intercollegiate athletics at Bellarmine University, the potential for a catastrophic injury does exist.
With this fact in mind, I understand the importance of the rules and the procedures as well as the necessity of using
proper techniques. Furthermore, I understand that the possibility of a catastrophic injury does exist even though I
follow all instruction as to proper technique. I understand that the team physicians will have the final authority to
eliminate me from further participation due to an injury, illness, or medical condition, which could represent a risk to
my safety and an undue liability risk to Bellarmine University.

Student-Athlete’s Signature: _________________________________________________
Parent/Guardian’s Signature: _________________________________________________ Bellarmine University Sports Medicine Page 5 of 5
Medical History Statement

I have completed this medical history questionnaire and answered it truthfully and to the best of my knowledge. I am prepared to answer
questions from the Bellarmine University medical staff (including team physicians, athletic trainers, nurses, and consultants) concerning this
medical history and medical conditions. I affirm also that I do not suffer from any disability, injury, condition, or complaint that I have NOT
DISCLOSED on this form. I also understand that it is my responsibility to bring any new medical condition or concern to the athletic trainer
at the beginning of each school semester. I further recognize the importance of fully and accurately disclosing my physical conditions, past
and present, to the Bellarmine University medical staff and its consultants as it may be a matter of life or death.
Student-Athlete’s Signature: _________________________________________________
Parent/Guardian’s Signature: ________________________________________________ Authorization to Treat & Authorization to Release Information
I give authorization to the athletic training staff, team physicians, health services, and the medical consultants of Bellarmine University to evaluate and treat any injuries that may occur during my participation in intercollegiate athletics. I also give authorization to the athletic training staff to make referrals for treatment to the team physicians and/or other medical consultants of Bellarmine University. I give authorization to the athletic training staff to communicate with the physicians, health services, and medical consultants of Bellarmine University about any injuries and inform the coaching staff of my particular sport(s) and my parents as to the nature of my injury (ies), limitations, and estimated time of return. Finally, I give authorization to the athletic training staff to share with the coaching staff emergency information as to my medical history (i.e., allergies, conditions, etc.) and insurance information which would be considered important for health care staff to have if I were in an accident and unable to give this information. I understand that this authorization is valid for one calendar year and that any or all of it may be revoked by me at any time by doing so in writing. Student-Athlete’s Signature: __________________________________________________ Parent/Guardian’s Signature: __________________________________________________ Bellarmine Physician Review
I have reviewed this health history at the time of this student-athlete’s Pre-participation Physical Exam.
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Bellarmine University Sports Medicine Review
_____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ Bellarmine University Sports Medicine

Source: http://athletics.bellarmine.edu/custompages/AthleticTraining/Revised%20Health%20History%20Questionnaire%202012.pdf