Questionnaire sportsmedical examination

Name:

Dat of birth: Phone:

Adress:Postal code:

City: Doctor / GP:

Date: Profession:

Reden for the examination:

Sportsparticipation:

Are you a professional / competitive / recreational athlete

SportPracticing sincetraining frequencytraining time

a. Since years x/week

b. Sinceyears x/week

c. Sinceyears x/week

d. Sinceyears x/week

Weekprogramme / Type of training / Length of training
Training 1 / Training 2
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

General questions

  1. Have you had a serious or long lasting injury in the past year?YesNo

Family doctor / GP:

  1. Do you agree with sending a copy of the report to your GP / sports doctor?YesNo

Have you ever been:

  1. Seriously ill or had a long lasting medical condition?YesNo
  2. Seen by a specialist in a hospital or clinic? YesNo
  3. Hospitalized? YesNo
  4. Do you feel healthy at the moment? YesNo
  1. Are you satisfied with your eating pattern?YesNo
  2. Do you worry about your weight / body composition?YesNo
  3. Are you a vegetarianYesNo
  4. Do you lose weight to meet weight requirements for your sport?YesNo
  5. Do you currently suffer or have you ever suffered an eating disorder?YesNo
  6. Do you take any vitamins, performance enhancers or other substances? YesNo
  1. Do you smoke? YesNo
  2. Do you drink alcohol? YesNo
  3. Do you take any medication? YesNo

Do you regularly suffer from:

16.Headaches, dizziness, balance disordersYesNo

  1. Epilepsy, concussion, migraineYesNo
  2. Sleep disturbancesYesNo
  3. Eyesight difficultiesYesNo
  4. Hearing difficulties, ear infections, ear acheYesNo
  1. Cold, hoarseness, sore throatYesNo
  2. Cough, shortness of breathYesNo
  3. Giving up sputum, bronchitis, emphysemaYesNo
  4. Hay fever, CARA, asthmaYesNo
  5. Chestpain or shortness of breath in rest or during exerciseYesNo
  6. Palpitations, irregular heartbeatYesNo
  7. High blood pressureYesNo
  8. Changes in appetite, swallowing difficultiesYesNo
  9. Nausea, vomiting, burpingYesNo
  10. Heartburn, stomach ulcer, belly acheYesNo
  11. Diarrhoea, constipationYesNo
  12. Losing or gaining weightYesNo
  13. Kidney or urinary tract problemsYesNo
  14. Pain during urinationYesNo
  15. Loss of urineYesNo
  1. Skin problemsYesNo
  2. DiabetesYesNo
  3. Thyroid gland problemsYesNo
  1. Muscle or tendon problemsYesNo
  2. Pain in neck, back or shouldersYesNo
  3. Pain in hips, knees, ankles, feet or toesYesNo
  4. Pain in elbows, wrists, hands or fingersYesNo

Are there family members with a history of:

  1. Stroke, cardiac diseaseYesNo
  2. High blood pressure YesNo
  3. Death under 55 years of ageYesNo
  4. Tuberculosis, asthmaYesNo
  5. Rheumatism YesNo
  6. CancerYesNo
  7. EpilepsyYesNo
  8. Back problemsYesNo

For women only:

  1. At what age was your first menstrual cycle?……………
  2. Do you have a regular menstrual cycyle?YesNo
  3. Do you take oral anticonception / the (prick) pill? YesNo
  4. Have you had a stressfracture in the past?YesNo
  5. Are you pregnant?YesNo

Signature:

………………………….…………