PREPARTICIPATION HEALTH HISTORY

(to be completed prior to examination)

 

 

Name:___________________________________________  D.O.B._______________________

 

Home Address:__________________________________________________________________

 

Telephone:__________________  Parent/Guardian Name:_______________________________

 

                                                                                                                        YES                 NO

  1. Have you ever been told not to participate in any

sports for health reasons?                                                                      ______            ______

 

  1. Have you ever had chest pain or discomfort when exercising?                ______            ______

 

  1. Have you ever fainted or passed out during

exercise?  Or at any other time?                                                            ______            ______

 

  1. Have you ever had excessive shortness of breath or fatigue

While exercising?                                                                                  ______            ______

 

  1. Has anyone in your immediate family died suddenly

before the age of 50?                                                                            ______            ______

 

  1. Has anyone in your family been disabled before the age of

50 because of heart disease?                                                                 ______            ______

 

  1. Do you have any family members with any of the following:

Hypertrophic or Dilated Cardiomyopathy; Long Q-T Syndrome

or other ion channelopathies, Marfan’s Syndrome; or clinically

important arrhythmias?                                                                          ______            ______

 

  1. Do you have asthma ( wheezing), coughing spells

or shortness of breathe during or after exercise?                                    ______            ______

 

  1. Have you ever had a concussion, lost consciousness

( been “knocked out”) or had memory loss after

a head injury?                                                                                       ______            ______

 

  1. Are you now being treated for or have you ever been treated

for any of the following: bleeding disorder; convulsions or

      seizures; diabetes; chronic headaches; heart disease;

      (including murmur, irregular heart beat or surgery); high

      blood pressure; kidney disease; liver disease; collapsed lung?                ______            ______

 

  1. Are you missing sight in one eye, hearing in one ear or

have only one testicle or kidney?                                                           ______            ______

 

  1. Have you ever had a neck or back injury / problems

(including “stingers” or “burners”)?                                                        ______            ______

 

  1. Have you ever broken (fractured) a bone or had to wear

a cast or splint?                                                                                     ______            ______

 

  1. Have you ever had an ankle or knee sprain, or dislocated

joint?                                                                                                    ______            ______

 

  1. Have you had any other serious injuries?                                               ______            ______

 

  1. Have you ever suffered heat exhaustion, heat stroke or

had other problems related to heat?                                                       ______            ______

 

  1. Have you ever been in the hospital overnight or had an

operation?                                                                                            ______            ______

 

  1. Do you wear contact lenses, eyeglasses or use a hearing aid?                 ______            ______

 

  1. Do you have allergies to medicines or bee stings?                                  ______            ______

 

  1. Do you take any medicines regularly, either prescription

or non-prescription?                                                                             ______            ______

 

  1. Are you currently being treated for an illness by a doctor

or other health care professional?                                                          ______            ______

 

  1. Do you have any worries about your health or other questions

you would like to discuss?                                                                     ______            ______

 

 

Explain any YES answers to the above:______________________________________________

__________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________

 

Signature of Athlete:_________________________________ Date:_______________________

 

Signature of Parent/Guardian:______________________________________________________

            (If athlete under 18 years old)

 

By signing this form you are verifying that all information provided is current and correct, you are also consenting to a physical exam by the school physician.

 

 

THIS PHYSICAL IS ONLY VALID FOR PARTICIPATION IN SWANSEA SCHOOL DEPARTMENT ATHLETICS.