SPORTS PARTICIPATION EXAMINATION HEALTH HISTORY
To be completed by athlete and parent. Please fill out completely.
Student’s Name: ______DOB: ______Age: ______
Sports to be played: ______
School: ELHS AMS LHS LMS LISBON FALLS
1. Please list any allergies you have (to medications, pollen, grass, bee stings hay fever, etc.) ______
2. Please list any medications (including prescriptions and over-the counter medications) that you take on a regular basis: ______
3. Please list any medications that you use for emergencies (such as inhalers, bee sting kits): ______
4. When was your last tetanus booster shot? ______
5. Please list any chronic illnesses you have (such as diabetes, epilepsy, asthma, etc.): ______
6. What kind of exercise have you been doing to get ready for the season?
______
7. During or after exercise, have you ever:
- been dizzy or passed out?………………………………. □ yes □ no
- had chest pain? ………………………………………… □ yes □ no
- had wheezing or trouble breathing?……………………. □ yes □ no
8. Have you ever:
a. been knocked out or had a concussion ……………………□ yes □ no
b. had a seizure? ……………………………………………..□ yes □ no
9. Have you ever been told that you had:
a. a heart murmur or irregular heart rhythm?………………..□ yes □ no
b. a heart abnormality?………………………………………□ yes □ no
c. high blood pressure?………………………………………□ yes □ no
10. Has any member of your family under the age of 50 had a heart attack, heart problem or died suddenly? ……………………………………………...□ yes □ no
If yes, relationship and condition: ______
11. Are you missing or have you ever damaged a major organ (eye, kidney, testicle, liver spleen, etc.)? ……………………………………………………….□ yes □ no
12. Have you ever had an illness or injury that:
a. required you to go to the Emergency Room or to see a doctor?…. □yes □no
b. required you to stay in the hospital or have an operation?………. □yes □no
c. required x-rays or a cast, splint, sling, cane, or crutches?….……..□yes □no
d. caused you to miss more than 3 days of practice or competition? □yes □no
13. Have you ever sprained/ strained, dislocated, fractured, broken, or had repeated swelling or other injury to any of the following body parts or joints?
□head □neck □back/spine □shoulder □elbow
□forearm □wrist □hand □finger □hip
□thigh □knee □shin/calf □ankle □foot
14. Please list any special equipment you use when you play sports (such as ankle tape, knee brace, protective goggle, mouth guard, etc.): ______
15. Do you wear glasses or contacts or have dental bridges, plates or braces? □yes □no
16. For girls only:
a. How old were you when you had your first menstrual period? ______
b. When was your last period? ______
c. During the past year, what was the longest time between your periods? _____
Please explain any “yes” answers:
______
______
I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
Signature of athlete: ______Date: ______
Signature of parent/guardian: ______Date: ______