Microsoft Word - UNCA HEALTH HISTORY FORM.doc



Name: Sport: Date: Date of Birth: Social Security Number: Please answer each of the following questions by checking either the “yes” or “no” box.Explain any “yes” answers in the space provided.Family HistoryHas any parent, grandparent, or sibling had:Cancer[ ] YES [ ] NO Leukemia[ ] YES [ ] NO Tuberculosis[ ] YES [ ] NO Diabetes[ ] YES [ ] NO Heart trouble[ ] YES [ ] NO High blood pressure[ ] YES [ ] NO Asthma[ ] YES [ ] NO Liver disease[ ] YES [ ] NO Migraine headaches[ ] YES [ ] NO Emphysema[ ] YES [ ] NO Stroke[ ] YES [ ] NO Epilepsy[ ] YES [ ] NO Stroke[ ] YES [ ] NO Bleeding Disorder[ ] YES [ ] NO Kidney disease[ ] YES [ ] NO Glaucoma[ ] YES [ ] NO Sickle Cell Anemia[ ] YES [ ] NO Other serious disease[ ] YES [ ] NO Sudden death before age 50[ ] YES [ ] NO Personal HistoryDo you smoke? [ ] YES [ ] NO Do you use other tobacco products?[ ] YES [ ] NO Do you drink alcohol? [ ] YES [ ] NO Does alcohol affect school? [ ] YES [ ] NO Received treatment for substance abuse? [ ] YES [ ] NO Are you on a special diet? [ ] YES [ ] NO Have you recently lost weight? [ ] YES [ ] NO Are you unsatisfied with your weight?[ ] YES [ ] NO Ever diagnosed with an eating disorder? [ ] YES [ ] NO Do you have difficultly sleeping? [ ] YES [ ] NO AllergiesLatex[ ] YES [ ] NO Penicillin/ other antibiotics[ ] YES [ ] NO Sulfa drugs[ ] YES [ ] NO Other drug/medicine[ ] YES [ ] NO Any food item[ ] YES [ ] NO Bee Stings[ ] YES [ ] NO Other allergy[ ] YES [ ] NO MedicationsCurrent tetanus vaccination[ ] YES [ ] NO give date of last vaccination: Are you currently taking medications?[ ] YES [ ] NO Have you ever taken:Thyroid medicine[ ] YES [ ] NO Blood pressure medicine[ ] YES [ ] NO Birth control pills[ ] YES [ ] NO Other medication[ ] YES [ ] NO Current Health StatusMUSCULOSKELETALHave you ever suffered a sprain, strain, dislocation, fracture or other injury to any of the following? Please give dates of injury and surgery information if applicable.Neck injury[ ] YES [ ] NO Shoulder injury[ ] YES [ ] NO Elbow injury[ ] YES [ ] NO Wrist/hand injury[ ] YES [ ] NO Back injury[ ] YES [ ] NO Hip injury[ ] YES [ ] NO Knee injury[ ] YES [ ] NO Ankle/foot injury[ ] YES [ ] NO Broken bone[ ] YES [ ] NO Stress fracture[ ] YES [ ] NO Other musculoskeletal problem[ ] YES [ ] NO Do you now, or have you had in the past any of the following?MusculoskeletalArthritis[ ] YES [ ] NO Swollen joints[ ] YES [ ] NO Loss of muscle strength[ ] YES [ ] NO Lump or swelling in muscle[ ] YES [ ] NO GeneralSYSTEMICDiabetes[ ] YES [ ] NO Controlled with insulin[ ] YES [ ] NO Thyroid disorder [ ] YES [ ] NO Hepatitis [ ] YES [ ] NO Anemia [ ] YES [ ] NO Sickle cell anemia [ ] YES [ ] NO Epilepsy/convulsions [ ] YES [ ] NO Rheumatic Fever [ ] YES [ ] NO Mononucleosis [ ] YES [ ] NO Poor blood clotting[ ] YES [ ] NO Fever [ ] YES [ ] NO Chills [ ] YES [ ] NO Aches and Pains [ ] YES [ ] NO General weakness [ ] YES [ ] NO Memory loss [ ] YES [ ] NO Swollen Glands [ ] YES [ ] NO Easy bruising [ ] YES [ ] NO Heat Related IllnessDehydration[ ] YES [ ] NO Heat cramps[ ] YES [ ] NO Heat exhaustion[ ] YES [ ] NO Heat stroke[ ] YES [ ] NO Have you ever:Felt dizzy during/after exercise [ ] YES [ ] NO Passed out during/after exercise [ ] YES [ ] NO Had muscle cramps[ ] YES [ ] NO HeadHay fever/Allergies[ ] YES [ ] NO Concussion[ ] YES [ ] NO Migraine headaches[ ] YES [ ] NO Severe headaches[ ] YES [ ] NO Face fracture[ ] YES [ ] NO Other head problem[ ] YES [ ] NO EyesContacts or glasses[ ] YES [ ] NO Glaucoma[ ] YES [ ] NO Cataracts[ ] YES [ ] NO Blindness (either eye)[ ] YES [ ] NO Blurred vision not corrected with lenses[ ] YES [ ] NO Double Vision[ ] YES [ ] NO Light flashes[ ] YES [ ] NO Halos around lights[ ] YES [ ] NO Pain in your eyes[ ] YES [ ] NO Eye fracture[ ] YES [ ] NO Other eye problem[ ] YES [ ] NO EarsEar infections[ ] YES [ ] NO Ear pain[ ] YES [ ] NO Drainage from ear[ ] YES [ ] NO Hearing difficulty or deafness[ ] YES [ ] NO Buzzing/ringing ears[ ] YES [ ] NO Other ear problem[ ] YES [ ] NO Mouth/NoseNosebleeds[ ] YES [ ] NO Nose fracture[ ] YES [ ] NO Sinus trouble[ ] YES [ ] NO Difficulty with swallowing[ ] YES [ ] NO False teeth or bridges[ ] YES [ ] NO Fractured or loose tooth[ ] YES [ ] NO Mouth, tooth, or tongue problem[ ] YES [ ] NO Other mouth/nose problem[ ] YES [ ] NO NeckSwelling[ ] YES [ ] NO Lumps[ ] YES [ ] NO Stiffness[ ] YES [ ] NO Burner or stinger[ ] YES [ ] NO Neck fracture[ ] YES [ ] NO Other neck problem[ ] YES [ ] NO SkinRecurrent boils[ ] YES [ ] NO Changing mole[ ] YES [ ] NO Rash[ ] YES [ ] NO Yellow skin[ ] YES [ ] NO Other skin problem[ ] YES [ ] NO Chest, Heart and LungsAsthma[ ] YES [ ] NO Controlled with medication[ ] YES [ ] NO Chronic Bronchitis[ ] YES [ ] NO Tuberculosis[ ] YES [ ] NO Shortness of breath[ ] YES [ ] NO Poor exercise tolerance[ ] YES [ ] NO High blood pressure[ ] YES [ ] NO Heart murmur[ ] YES [ ] NO Unusual heartbeat[ ] YES [ ] NO Chest pains or pressure attacks[ ] YES [ ] NO Frequent cough[ ] YES [ ] NO Coughing up blood[ ] YES [ ] NO Wheezing[ ] YES [ ] NO Night sweats[ ] YES [ ] NO Swollen ankles[ ] YES [ ] NO Leg cramps[ ] YES [ ] NO Other chest problem[ ] YES [ ] NO Other heart problem[ ] YES [ ] NO Other lung problem[ ] YES [ ] NO GastrointestinalIndigestion or heartburn[ ] YES [ ] NO Stomach or Duodenal Ulcer[ ] YES [ ] NO Colon trouble[ ] YES [ ] NO Rectal trouble[ ] YES [ ] NO Poor appetite[ ] YES [ ] NO Nausea/vomiting[ ] YES [ ] NO Abdominal pain or cramps[ ] YES [ ] NO Change in bowel habits[ ] YES [ ] NO Blood in stool[ ] YES [ ] NO Other gastrointestinal problem[ ] YES [ ] NO NeuromuscularWeakness in arm or leg[ ] YES [ ] NO Numbness in arm or leg[ ] YES [ ] NO Tingling in arm or leg[ ] YES [ ] NO Balance difficulty[ ] YES [ ] NO Dizzy spells[ ] YES [ ] NO Fainting spells[ ] YES [ ] NO Speech difficulty[ ] YES [ ] NO Other neuromuscular problem[ ] YES [ ] NO UrinaryBladder/Urinary tract infection[ ] YES [ ] NO Kidney infection[ ] YES [ ] NO Kidney stones[ ] YES [ ] NO Loss of kidney[ ] YES [ ] NO Other kidney disease[ ] YES [ ] NO MALES ONLYLump in testicles[ ] YES [ ] NO Loss of a testicle[ ] YES [ ] NO Hernia[ ] YES [ ] NO Other problem[ ] YES [ ] NO FEMALES ONLYBreast lump[ ] YES [ ] NO Discharge from nipple[ ] YES [ ] NO Other breast problem[ ] YES [ ] NO Vaginal bleeding or spotting notassociated with periods[ ] YES [ ] NO Pain with periods[ ] YES [ ] NO Change in periods[ ] YES [ ] NO Irregular periods[ ] YES [ ] NO Lack of periods[ ] YES [ ] NO Ovarian cyst[ ] YES [ ] NO Other GYN problems[ ] YES [ ] NO PsychologicalSerious depression[ ] YES [ ] NO Serious emotional problem[ ] YES [ ] NO Do you find your life:Generally unsatisfying[ ] YES [ ] NO Too demanding[ ] YES [ ] NO Boring[ ] YES [ ] NO Do you worry about:Food [ ] YES [ ] NO Money[ ] YES [ ] NO School [ ] YES [ ] NO Weight[ ] YES [ ] NO Parents/family[ ] YES [ ] NO Boyfriend/girlfriend[ ] YES [ ] NO Do you:Often feel depressed[ ] YES [ ] NO Cry easily[ ] YES [ ] NO Feel inferior to others[ ] YES [ ] NO Feel shy[ ] YES [ ] NO Feel things often go wrong[ ] YES [ ] NO Feel overstressed[ ] YES [ ] NO Feel anxious or upset[ ] YES [ ] NO Are you currently under the care of a physician for any injury or medical condition?[ ] YES [ ] NO If yes, please explain:Physician’s name and phone number: Injury or condition: Current treatment: Do you have any condition or disease not listed on this form?[ ] YES [ ] NO If yes, please explain:I, (print full name) the undersigned, herewith:a. Understand that I must refrain from practice or play while ill or injured, whether or not receiving medical treatment until I am discharged from treatment or given permission by the Certified Athletic Trainer and/or Team Physician to restart participation despite continuing treatment.b. Understand that having passed the physical examination does not necessarily mean that I am physically qualified to engage in athletics, but only that the examiner did not find a medical reason to disqualify at the time of said examination.c. Give permission to the Athletic Training Staff and Team Physicians to discuss medical conditions pertaining to athletic participation.d. Certify that the answers given to the questions above are correct and true to the best of my knowledge.Athlete Signature: Date: Parent/Guardian Signature: (if athlete is under 18 years of age)Reviewed by ATC: Date: Date: ................
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