Medical
History Form
Name
Last_________________________________First___________________________________Middle____________
SSN
________-______-________ DOB________/______/________ Age________ Sex__________
Local
Address_________________________________________________ Local Phone #(______)_____________
Apt.#__________ City______________________________ State_______________ Zip__________
Mother/Guardian_______________________________________ Home Phone #(______)____________________
DOB______/____/______ Work Phone
#(______)________________________
Father/Guardian________________________________________ Home Phone #(______)____________________
DOB______/____/______ Work Phone
#(______)________________________
Permanent
Address__________________________________________________________________________________
Apt.
#___________ City_______________________________ State_______________ Zip__________
_____________________________________________________________________________
1. Have you had a medical illness, injury, or surgery since your last check up or sports physical? Yes No
Describe____________________________________________________________________________________________________
2. Have you ever been hospitalized overnight? Yes No
If yes, for what_______________________________________________________________________________________________
3. Do you currently have any ongoing chronic illness? Yes No
Describe____________________________________________________________________________________________________
4. Have you ever had surgery? Yes No
Describe____________________________________________________________________________________________________
5. Are you currently taking any prescription or nonprescription(over-the-counter) medications, pills, or inhalers? Yes No
List________________________________________________________________________________________________________
6. Have you ever taken any supplements or vitamins to help you gain or lose weight or improve performance? Yes No
List________________________________________________________________________________________________________
7. Do you have any known allergies to environmental agents, medications, foods, or insects? Yes No
List________________________________________________________________________________________________________
8. Have you been diagnosed with a severe viral infection (i.e. mononucleosis) within the last month? Yes No
Describe____________________________________________________________________________________________________
9. Do you cough, wheeze, or have trouble breathing during or after activity? Yes No
10. Do you have asthma? Yes No
If yes, what medications are you taking?___________________________________________________________________________
11. Have you ever passed out during or after exercise? Yes No
12. Have you ever felt dizzy during or after exercise? Yes No
Describe____________________________________________________________________________________________________
13. Have you ever suffered from heat cramps, heat exhaustion, or heat stroke? Yes No
Describe____________________________________________________________________________________________________
14. Have you ever had a rash or hives develop during or after exercise? Yes No
15. Do you have any current skin problems? (i.e. rashes, acne, itching, warts, fungus, blisters) Yes No
Describe____________________________________________________________________________________________________
16. Have you had any problems with your eyes or vision? Yes No
17. Do you wear glasses, contacts, or protective eyewear? Yes No
Describe____________________________________________________________________________________________________
18. Were you born with a complete set of paired organs? (i.e. eyes, ears, kidneys, ovaries, testicles, lungs) Yes No
If not, which organs___________________________________________________________________________________________
19. Have you ever had surgery to repair or remove an organ? (i.e. hernia, tonsils, appendix, spleen) Yes No
Describe____________________________________________________________________________________________________
20. Have you ever been diagnosed as being iron deficient or suffered from uncontrollable bleeding? Yes No
21. Have you or any of your family members ever been diagnosed with sickle cell trait? Yes No
If yes, which member? Mother____ Father____ Brother____ Sister____ Grandmother ____ Grandfather____ Aunts/Uncles____
22. Have you ever experienced chest pains before, during, or after exercise? Yes No
Describe____________________________________________________________________________________________________
23. Do you get tired more quickly than your friends do during exercise? Yes No
24. Have you ever been diagnosed with and irregular heartbeat? Yes No
25. Have you ever been diagnosed with high blood pressure or high cholesterol? Yes No
26. Have you ever been diagnosed with a heart murmur? Yes No
Decribe_____________________________________________________________________________________________________
27. Has any family member or relative died of a heart condition or of sudden death before the age of 50? Yes No
If yes, which member? Mother____ Father____ Brother____ Sister____ Grandmother____ Grandfather____ Aunts/Uncles_____
28. Has a physician ever denied or restricted your participation in sports for a heart-related problem? Yes No
Describe____________________________________________________________________________________________________
29. Have you ever suffered a head injury or concussion? Yes No
30. Have you ever been knocked out, become unconscious, or lost memory? Yes No
Describe____________________________________________________________________________________________________
31. Have you ever had a seizure? Yes No
32. Do you have frequent or severe headaches? (i.e. migraines) Yes No
Describe____________________________________________________________________________________________________
33. Have you ever had numbness or tingling in your arms, hands, legs, or feet? Yes No
34. Have you ever had a burner, stinger, or pinched nerve? Yes No
Describe____________________________________________________________________________________________________
35. Have you ever fractured any bones or dislocated any joints? Yes No
Describe____________________________________________________________________________________________________
36. Have you ever sprained or torn ligaments to any joint? Yes No
Describe____________________________________________________________________________________________________
37. Have you ever strained or torn any muscles? Yes No
Describe____________________________________________________________________________________________________
38. Have you ever had tendonitis, bursitis, or Osgood Schlatter’s? Yes No
Describe____________________________________________________________________________________________________
39. Do you use any special protective or corrective equipment or devices when competing in athletics? Yes No
Describe____________________________________________________________________________________________________
40. Are there any additional health problems you would prefer to discuss privately with our team physician? Yes No
Females Only – confidential
41. When was your first menstrual period? _______
42. When was your most recent menstrual period? _______
43. How much time do you usually have from the start of one period to the start of another? _______
44. How many periods have you had in the last year? _______
45. Are you currently taking any form of birth control medication? Yes No
If yes, describe_______________________________________________________________________________________________
The undersigned,
herewith,
A. Understands that he/she must refrain from practice or play during medical treatment until he/she is discharged from treatment or given a written permit by the attending physician to resume participation.
B. Certifies the answers to these questions are correct and true.
C. Understands that his/her having passed the physician examination does not necessarily mean that he/she is physically qualified to engage in athletics, but only that the examiner did not find medical reason to disqualify him/her.
D. Fully realizes the Tyler Junior College Athletic Department cannot be held responsible to any previous medical condition(s) that he/she might have.
Signature__________________________________________________________ Date________________________________