Shaw University Sports Medicine
Student-Athlete
Medical History and Physical
Last Name (print / First Name / Middle Initial / Social Security NumberHome Address (Number & Street) / City / State / Zip / Telephone Number
Date of Birth / Gender / Marital Status
Year of Graduation / Semester of Registration
Insurance Company / Policy Number
Name/ Relationship of Next of Kin
Address/Phone of Next of Kin
PERSONAL HISTORY PLEASE ANSWER ALL QUESTIONS Comment on all positive answers in space below or on additional sheet
Have You Had / Yes / No / Have You Had / Yes / No / Have You Had / Yes / No / Have You Had / Yes / NoEye Trouble / Frequent or sever Respiratory Infections / Kidney or Bladder Disease / Diabetes
Ear, Nose, Throat / Rheumatic Fever or Heart Mummer / Disease or Injury of Bones or joints / Infect. Mononucleosis
Frequent or Sever Headaches / Stomach or Intestinal Trouble / “Trick” Knee or Shoulder / Sickle Anemia
Epilepsy / Females only
Asthma, Hay fever, Hives / Hepatitis or Jaundice / Asthma / Irregular Period
Tuberculosis / Severe Cramps
Excessive Flow
Yes / No
A. Do you have any disease, or is any drug or other treatment being followed, which should be continued or periodically evaluated? (Details)
B. Have you any drug allergy or other known sensitivity or intolerance? (Details)
C. Have you had any illness, injury, or operation or been hospitalized other than as already noted? (Details)
D. Has your physical activity been restricted during the past five years? (Why)
E. Have you ever been hospitalized for mental or emotional illness? {Give Names and address of doctors and/or hospitals}
F. Have you ever interrupted school or work either because of mental or emotional illness or after psychiatric consultation? {Give Names and address of doctors and/or hospitals} /
To the Examining Physician: Please review the student-athletes history and complete the physician’s form. Please comment on all positive answers. The information supplied will be used as a background for providing health care. This information is strictly for Sports Medicine and will not be released without the students consent.
Last Name / First Name / Middle NameHeight: ______Inches / Weight: ______lbs. / B.P. ______/______/ Pulse: ______min.
Corrected Vision: / Hearing (gross):
Right:______/ Left: ______/ Right: ______/ Left: ______
Urinalysis
Sugar: ______
Albumin: ______
Micro: ______
Hematocrit (if indicated Sickle Cell:
______%
/
Are there any abnormalities? / Yes / No
Head, Ears, Nose, Throat
Eyes
Respiratory
Cardiovascular
Gastrointestinal
Hernia
Genitourinary
Musculoskeletal
Shoulders
Hips
Knees
Ankles
Feet
Metabolic/Endocrine
Neuropsychiatric
Skin
Mammary