Yes

No

1.

Have you ever been hospitalized?
Have you ever had surgery?

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2.

Are you presently taking any medications or pills?

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3.

Do you have any allergies (medicine, bees or other stinging insects)?

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4.

Have you ever passed out during or after exercise?
Have you ever been dizzy during or after exercise?
Have you ever had chest pain during or after exercise?
Do you tire more quickly than your friends during exercise?
Have you ever had high blood pressure?
Have you ever been told that you have a heart murmur?
Have you ever had racing of your heart or skipped heartbeats?
Has anyone in your family died of heart problems or sudden death before age 50?

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5.

Do you have any skin problems (itching, rashes, acne)?

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6.

Have you ever had a head injury?
Have you ever been knocked out or unconscious?
Have you ever had a seizure?
Have you ever had a stinger, burner or pinched nerve?

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7.

Have you ever had heat or muscle cramps?
Have you ever been dizzy or passed out in the heat?

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8.

Do you have trouble breathing or do you cough during or after activity?

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9.

Do you have any special equipment (pads, braces, neck rolls, mouth guard, eye guards, etc.)?

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10.

Have you had any problems with your eyes or vision?
Do you wear glasses or contacts or protective eye wear?

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11.

Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injuries of any bones or joints?
( ) Head ( ) Shoulder ( ) Thigh ( ) Neck ( ) Elbow ( ) Knee ( ) Chest
( ) Forearm ( ) Shin/calf ( ) Back ( ) Wrist ( ) Ankle ( ) Hip ( ) Hand ( ) Foot

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12.

Have you had any other medical problems (infectious mononucleosis, diabetes, etc.)?

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13.

Have you had a medical problem or injury since your last evaluation?

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14.

When was your last tetanus shot?
When was your last measles immunization?

15.

When was your first menstrual period?
When was your last menstrual period?
What was the longest time between your periods last year?