Rockford UniversityHealth History FormStudent Athlete: Yes___ No___

Name______Date of Birth ______

Last First Middle Int.

Home Address______

StreetCity StateZip Code

Campus Box ______Cell Phone ______Email______

Emergency Contact______Relation______Cell Phone______

PAST/CURRENT PERSONAL MEDICAL HISTORY:Have you ever had any of the following?Check all thatapply.

Family History: / Yes / No / Additional Comments
Does anyone in your family have or have they ever hadhigh blood pressure?
Does anyone in your familyhave or have they ever had high cholesterol?
Does anyone in your family have or have they ever hadheart disease (including heart attack or congenital disorders)?
Does anyone in your family have or have they ever haddiabetes?
Does anyone in your family have or have they ever hadAsthma?
Does anyone in your family have or have they ever had Sickle Cell Anemia?

______

Lifestyle Review: / Yes / No / Additional Comments
Do you drink caffeinated beverages such as coffee, black teas or cola?
Do you use tobacco products (cigarettes, cigars, snuff/chewing tobacco)?
Do you drink alcohol?
Do you usually drink more than 4 or 5 drinks in one social session?
Have you felt you ought to cut down on your drinking?
Do you use marijuana, or any other street or recreational drugs?
If so, what kind and how often?
Do you do any physical activity?
If so, what type and how often?
Have you lived or traveled outside the U.S. in the last two years?
If so, where?
Do you have concerns regarding sexuality or gender orientation?
Are sexually transmitted infections or pregnancy prevention a concern?
Do you have concerns about your weight?
Are you on a special diet?

______

Stress/Emotional Health: / Yes / No / Additional Comments
Have you experienced major changes or problems in the past year
(e.g. personal or family relationships, finances, job)? If so, please explain:
Have you felt anxious much of the time in the past year? If so, have you
received counseling and /or medication?
Have you felt sad or depressed much of the time in the past
year? If so, have you received counseling and/or medication?
Has anyone ever sexually, physically or emotionally abused you
(including repeated hitting, name-calling, or loud criticism;
childhood sexual touching by someone older than you; or rape)?
Would you like to discuss stress/emotional concerns?
Would you like to discuss any other concerns including social, cultural,
religious, or gender-related issues?

______

Exercise: / Yes / No / Additional Comments
Has a doctor ever denied or restricted your participation in sports for any reason?
Have your ever passed out or nearly passed out during or after exercise?
Have you ever had discomfort, pain, tightness or pressure in your chest during exercise?
Does your heart ever race or skip beats (irregular beats) during exercise?
Do you have frequent muscle cramps when exercising?

I HEREBY STATE THAT MY ANSWERS ON THIS HEALTH HISTORY FORM ARE COMPLETE AND CORRECT:

Signature______Date______