Sports Physical Health History

Patient Name:	Date of Birth:

Gender: Age: School:	Grade:

What sports do you play?

Street Address:

City: State: Zip:

Parent’s Email Address:

Phone:

Please list all of the PRESCRIPTION AND OTC MEDICATIONS that you are currently taking:

Medication: Dosage: Frequency: per Day Wk Mo

Medication: Dosage: Frequency: per Day Wk Mo

Medication: Dosage: Frequency: per Day Wk Mo

Please list all of the SUPPLEMENTS that you are currently taking:

Medication: Dosage: Frequency: per Day Wk Mo

Other Frequency (please describe):

Medication: Dosage: Frequency: per Day Wk Mo

Other Frequency (please describe):

Medication: Dosage: Frequency: per Day Wk Mo

Other Frequency (please describe):

ALLERGIES:

Do You have any allergies? Yes No If yes, please identify and specify below:

Medicines Pollens Food Stinging Insects Other

Specify any ALLERGIES TO MEDICATIONS:

Specify ALLERGIES TO POLLENS, FOOD AND INSECT ALLERGIES:

General Questions	YES	NO
1a. Has a doctor ever denied or restricted your participation in sports for any reason?	x
1b. Have you had a medical illness or injury since your last sports physical?
2.. Do you have any ongoing medical conditions such as Asthma, Anemia, Diabetes, Infections..ect? If yes, please identify below:
3. Have you ever spent the night in the hospital?
4. Have you ever had surgery?
Heart Health Questions	YES	NO
5. Have you ever passed out or nearly passed out during or after exercise?
6. Have you ever had pain, tightness or pressure in your chest during exercise?
7. Does your heart ever race or skip beats during exercise?
8. Has a doctor ever told you that you have any heart problems? If yes, please identify below: High blood pressure High cholesterol Kawasaki disease Heart murmur Heart infection Specify:
9. Has a doctor ever ordered a test for your heart? (ECG/EKG, echo, ect)
10. Do you get lightheaded or feel more short of breath than expected during exercise?
11. Have you ever had an unexpected seizure?
12. Do you get more tired or short of breath more quickly than your friends during exercise?
Family Heart Health Questions	YES	NO
13. Have any of your relatives/family members died of heart problems or had any unexplained/unexpected death before age 50? (including drowning, unexplained car accident, or sudden infant death syndrome)
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmic right ventricular cariomyopathy, long/short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?
15. Does anyone in your family have a heart problem, pacemaker or other device?
16. Has anyone in your family had unexplained seizures or near drowning?
Bone and Joint Questions	YES	NO
17. Have you ever had a bone, muscle, ligament or tendon injury that caused you to miss practice/games?
18. Have you ever broken/fractured bones or dislocated joints?
19. Have you ever had an injury that required x-rays, MRI, CT scan, injection, therapy, a brace/cast or crutches?
20. Have you ever had a stress fracture?
21. Have you ever been told that you have or have had an xray for neck instability or atlantoaxial instability? (down syndrome or dwarfism)
22. Do you regularly use a brace, orthotics, or other assistive device?
23. Do any of your joints become painful, swollen, feel warm or look red?
24. Do you have a history of juvenile arthritis or connective tissue disease?
25. Do you have a bone, muscle or joint injury that bothers you? If yes, please identify below: Head Neck Back Chest Shoulder Upper Arm Elbow Forearm Wrist Hand Hip Thigh Knee Shin/Calf Ankle Foot Specify:
Medical Questions	Yes	No
26. Do you cough, wheeze or have difficulty breathing during or after exercise?
27. Have you ever used an inhaler or taken asthma medicine?
28. Is there anyone in your family who has asthma?
29. Were you born without or are you missing a kidney, eye, testicle (males), your spleen or other organ?
30. Do you have groin pain or a painful bulge or hernia in the groin area?
31. Have you had infectious mononucleosis within the last month?
32. Do you have any rashes, pressure sores or other skin problems?
33. Have you ever had a herpes or MRSA skin infection?
34. Have you ever had a head injury or concussion?
35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache or memory problems?
36. Do you have a history of seizure disorder?
37. Do you get headaches with exercise?
38. Have you ever had numbness, tingling or weakness in your arms of legs after being hit or falling?
39. Have you ever been unable to move your arms or legs after being hit or falling?
40. Have you ever become ill while exercising in the heat?
41. Do you get frequent muscle cramps while exercising?
42. Do you or someone in you family have sickle cell trait or disease?
43. Have you had any problems with your eyes or vision?
44. Have you had any eye injuries?
45. Do you wear glasses or contacts?
46. Do you wear protective eyewear such as goggles or a face shield?
47. Do you worry about your weight?
48. Are you trying to or has anyone recommended that you gain or lose weight?
49. Are you on a special diet or do you avoid certain types of foods?
50. Have you ever had an eating disorder?
51. Do you have any concerns that you would like to discuss with a doctor?
Females Only	Yes	No
52. Have you ever had a menstrual period?
53. How old were you when you had your first menstrual period? Age _______
54. How many periods have you had in the last 12 months? # _______

Explain YES Answers Below:

In order to SAVE TIME during your sports physical, please explain all “YES” answers below. Include the question number and then the explanation.

Yes Answers: