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: ______________________________________________________