MILLIGAN COLLEGE SPORTS MEDICINE PRE-PARTICIPATION ...

MILLIGAN COLLEGE SPORTS MEDICINE PRE-PARTICIPATION PHYSICAL EXAMINATION

Name: _______________________________________

Sport(s): ____________________________________

Height Weight Blood Pressure Pulse Vision Abdomen Head

Skin Ears Nose Throat - Mouth Lungs

(To be filled out by Milligan College Sports Medicine Staff or Your Doctor)

FRESHMAN SOPHOMORE

JUNIOR

SENIOR

FIFTH

Date:

Date:

Date:

Date:

Date:

R)20/ L)20/ R)20/ L)20/ R)20/ L)20/ R)20/ L)20/ R)20/ L)20/

Heart Hernia Genetalia Neurological

Orthopeadic

Accept: Reject: Hold:

Accept: Reject: Hold:

MD: Note:

MD: Note:

Accept: Reject: Hold:

Accept: Reject: Hold:

Accept: Reject: Hold:

MD: Note:

MD: Note:

MD: Note:

MILLIGAN COLLEGE SPORTS MEDICINE MEDICAL HISTORY FORM

Please print or type all answers.

Name _________________________________________________ Sport(s)_________________________

Last

First

Middle

Date of Birth ______________ Student ID# ______________ Social Security # ________-_______-______

MM/DD/YY

Home Address ____________________________________________________________________________

Street / Apartment #

______________________________________________ Cell Phone (_________)_______________________

City, State, Zip

Area Code

Father/Guardian _________________________________________________________________________

(First)

(Middle)

(Last)

Address _________________________________________________________________________________

Street Address

City, State, Zip

Home Phone (________)____________________ Business Phone (________)________________________

Area Code

Area Code

Cell Phone (__________)_______________________

Mother/Guardian ________________________________________________________________________

(First)

(Middle)

(Last)

Address _________________________________________________________________________________

Street Address

City, State, Zip

Home Phone (________)____________________ Business Phone (________)________________________

Area Code

Area Code

Cell Phone (__________)_______________________

If No Answer Call __________________________________________(_________)____________________

Name

Relation

Area Code

Phone

Medical information withheld, incomplete, or incorrect relieves Milligan College from all Medico-Legal liability and may disqualify you from participation on any Milligan College Athletic Team.

Instructions: When reply is yes, please give date of injury or treatment. Please indicate as near as possible the site of injury, left or right. Please be sure to answer completely, thoroughly and accurately, and remember that any medical information withheld, incomplete, or incorrect relieves Milligan College from all Medico-Legal liability and may disqualify you from participation on any Milligan College Athletic Team.

CIRCLE THE APPROPRIATE ANSWER:

General Medical

Yes No 1. Have you ever experienced an epileptic seizure or been informed you might have epilepsy?

Yes No 2. Have you had hepatitis during the past three years?

Yes No 3. Have you been treated for infections, mononucleosis, virus pneumonia, or any other infectious disease during the past 12 months?

Yes No 4. Have you or anyone in your family ever been treated for diabetes?

Yes No 5. Have you ever been told that you have a heart murmur? Heart disease or heart troubles?

Yes No 6. Has anyone in your family under the age of 30 been treated for, or is being treated for a heart condition? If yes, please explain. _______________________________

Yes No 7. Have you ever had chickenpox, measles, mumps, small pox?

Yes No 8. Have you ever had a kidney disease, bladder problem, or painful urination?

Yes No 9. Are you susceptible to colds, or sore throat?

Yes No 10. Have you ever had an ulcer?

Yes No 11. Have you ever had bronchitis?

Yes No 12. Have you ever had asthma? If yes, what medications are you presently taking? _________________________________________________________________________

Yes No 13. Have you ever had tonsillitis or a tonsillectomy?

Yes No 14. Have you ever had tuberculosis?

Yes No 15. Have you ever had appendicitis or appendectomy?

Yes No 16. Have you ever had a hernia or rupture?

Yes No 17. List any allergies that you may have.

_____ Bee sting, insect bite _____ Food. Please list: _________________________________________ _____ Drugs. Please list: _________________________________________ _____ Other. Please list: _________________________________________

Yes No 18. Have you had any illness requiring bed rest of one week or longer during the past year? If so, give date and nature of illness. __________________________________________

Yes No 19. Have you ever experienced heat exhaustion and/or heat stroke? If yes, when? ___________

Yes No 20. Have you had any operation during the past two years? If yes, indicate site of operation and date. _______________________________________________

Yes No 21. Have you ever been advised by a physician not to participate in sports? For what reason? __________________________________________________________________________

Yes No 22. Are you currently taking any prescription medication? If yes, please list. ________________________________________________________________

Yes No

23. Do you currently take any nutritional or performance aids? (ex. Vitamin/mineral supplements, creatine, androsteindione, etc.) If yes, please list. _______________________ __________________________________________________________________________

Yes No 24. Have you had any organs removed? If yes, why and when. __________________________

25. What is the date of your last tetanus vaccination? _________________________________

Head / Neck

Yes No

26. Have you ever been "knocked out" or experienced a concussion during the past three years. If so, give dates. __________________________________________________

Yes No

27. If answer to question 19 is yes, have you been "knocked out" more than once? Give dates. _________________________________________________________________

Yes No

28. If answer to question 19 and 20 is yes, did the attending physician have you stay overnight in a hospital? If yes, give dates and details. _______________________________

Yes No 29. Have you ever had a "stinger" or "burner"? If yes, how often?

Yes No 30. Have you had any fainting spells? If yes, give dates. _______________________________

Eye / Dental

Yes No 31. Do you wear glasses? Do you wear them during athletic competition? ________________

Yes No 32. Do you wear contact lenses? Do you wear them during athletic competition? ___________

Yes No 33. Do you keep spare sets of contacts and/or glasses?

Yes No 34. Do you have sight in both eyes?

Yes No 35. Do you wear any dental appliance? If answer is yes, circle appropriate appliance: bridge, permanent crown or jacket, removable partial, full plate, retainer, or braces

Yes No 36. Do you have any dead teeth? Please indicate approximate location of dead tooth or teeth. __________________________________________________________________________

Yes No 37. Do you have any teeth missing? If yes, how many and where?________________________

Yes No 38. Have you ever had any teeth knocked out or chipped? If so, when? ____________________

Bone and Joint

Yes No 39. Have you ever had a neck or spinal injury?

Yes No 40. Have you ever fractured a vertebra?

41. List any spinal conditions that you may have (scoliosis, herniated disc, kyphosis, etc.). ______________________________________________________________________

42. List any surgery you have had on your neck or spine. ___________________________ ______________________________________________________________________

Yes No 43. Have you ever fractured your humerus, clavicle, or scapula? If yes, which one and when. ______________________________________________________________________

Yes No 44. Have you ever dislocated your shoulder, acromioclavicular, or sternoclavicular joint? If Yes, which one and when. ________________________________________________

Yes No 45. Have you significantly sprained any of the above joints and were held from participation for more than one day? If yes, which and when. ______________________________

Yes No

46. List any surgeries that you have had on your shoulder. __________________________ ______________________________________________________________________

47. Have you fractured a bone in your arm, wrist, hand, or fingers? If yes, which and when. ______________________________________________________________________ ______________________________________________________________________

Yes No

48. Have you ever dislocated your elbow, wrist, or fingers? If yes, which and when. ______________________________________________________________________ ______________________________________________________________________

Yes No

49. Have you significantly sprained your elbow, wrist, hand, or fingers and were held from Participation for more than one day? If yes, which and when. ____________________ ______________________________________________________________________ ______________________________________________________________________

50. List any surgeries that you have had on your elbow, wrist, hand, or fingers. ______________________________________________________________________ ______________________________________________________________________

Yes No 51. Have you ever fractured a rib? If yes, when and which number. ___________________ ______________________________________________________________________

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