Health Questionnaire for Sports Participation

Please answer each question below. Those marked yes, please explain below to the best of your ability.

	Circle One
1. Have you ever been in a hospital for an operation or other reason?	NO	YES
2. Do you take any kind of medicine every day?	NO	YES
3. Do you have asthma or allergies (hives, medicine, bee sting)?	NO	YES
4. Are you under a physician’s care for any problems now?	NO	YES
5. Have you ever felt dizzy or had chest pains during or after exercise?	NO	YES
6. Do you have a heart murmur or other heart conditions?	NO	YES
7. Have you ever fainted or “blacked out” during exercise?	NO	YES
8. Have you ever had a heat illness such as heat exhaustion or stroke?	NO	YES
9. Have you ever had a concussion or suffered loss of consciousness or memory?	NO	YES
10. Have you ever had a fracture, dislocation, sprain, strain or other injury toany body part?	NO	YES
11. Do you have any eye problems, wear glasses or contacts?	NO	YES
12. Have you ever been told not to participate in any sport?	NO	YES

EXPLAIN “YES” ANSWERED QUESTIONS: _________________________________________________

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DATE OF LAST TETANUS BOOSTER: ______________________________________________________