TAMIU ATHLETICSPREPARTICIPATION PHYSICAL EVALUATION - MEDICAL HISTORY

REVISED 7122lUl

,This MEDICAL mSTORY FORM must be completed annually in order for the student to participate in athletic activities. Thesequestions are designed to determine if the student has developed any condition, which would make it hazardous to participate in anathletic event. .•Name: __ _ Sex Age Date ofbirth _Address: Phone _Personal Physician Phone _In case 01emergency, contact:Name___________ _ __.Relationship___ _ _Phone(H) (W) _

VesNoIJIJIJIJ

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IJHipIJThighIJKneeIJ Shin/CalfIJAnkle

10. Have you had any problems with your eyes or vision?11. Arc you miuing any paired organs?12. Do you usc any special protective or corrective equipment or

devices that aren't usually used for your sport or position (foreX8J11lle. knee brace, special neck roll, foot orthotics, retaineron your teeth, hearing aid)?

13. Have you ever had a.sprain, strain, or swelling after injury?Have you broken or fraCbJred any bones or dislocated anyjoints?Have you had any other problems with pain or swelling inmuscles. tendons, bones, or joints?If yes, check appropriate box and explain below.

IJHead Q ElbowIJNeck IJ Foreanna Back Q WristIJChest IJ HandtJ Shoulder a FingerIJUpperArm Q OTHERQFoot

14.DoyouW1ll1t toweighmoro(M)orless(L)thanyoudonow? M LDo you Jose weight regularly to meet weight requirements foryour sport?

1S. Do you feci stressed out?16. Dates of your most recent immunizations (shots) and tests for:

QTetanu.____ IJMMR _a Hepatitis B a Tuberculosis _

17. Arc you under a doctor's care?F••• .m o../y18. When was your first menstrual period? _

When was your most recent menstrual period? _How much time do you usually have from the start of oneperiod to the start ofanothcr? _How many periods have you had in the last ~ _What was the longest time between periods in the Jast year? _

Explain .Ye.f" answers here: fA 'Yes" 011 questions J. 2. 7, J J or J 7require.f a further medical evaluation which may include a pbysicalexamination. _

1. Have you had a medical iUness or injury since your last check uporsports phy.lical? IJIJ

2. Have you been hospitalized overnight in the past year? tJ ClHave you had surgery in the past year? a a

3. Are you currently taking any PTCSCription or non-prescription(over-the-counter) medication or piUs or using an inhaler? a a

4. Do you have any allergies (for example. to pollen. medicine,food. or stinging insects)? a a

S. Have you ever passed out during or after exercise? [] aHave you ever been dizzy during or after exercise? a aHave you ever had chest pain during or after exercise? [J DDo you get tired more quickly than your friends do duringexercise? a aHave you ever had racing of your heart or skipped heartbeats? Q 0Have you had high blood pressure or high cholesterol? QQHave you ever been told you have a heart rnul11'JJr? QQHas any family member or relative died of heart problems or ofsudden unexpected death before age SO? Q aHas any family member been diagnosed with enlarged heart.hypertrophic cardiomyopathy, long QT syndrome, Marfan'ssyndrome, or abnormal heart rhythm)? aQHave you had a severe viral infection (for example, myocarditisor mononucleosis) within the last month? Q aHas a physician ever denied or rcsbicted your participation insports for 8I1yheart problems? Q a

6. Do you have any current skin problems (for example, itching,rashes. acne, warts, fungus, or "listers)? Q Q

7. Have you ever bad a head injury or concussion? Q aHave you ever been knocked out, become unconscious, or lostyourmemory? IJIJIf yes, how many timcs? __ When was the last concussion? __How severe was each one? (Explain below)Have you ever had a seizure? Q QDo you have frequent or severe headaches? Q aHave you ever bad numbness or tingling in your arms, hands,legs,orfeet? IJIJHave you ever had a stinger, burner, or pinched nerve? CO

8. Have you ever become i11 from exercising in the heat? Q Q9. Have you ever gotten unexpectedly short of breath with exercise? Q Q

Do you cough, wheeze, or have trouble breathing during or afteractivity'? a QDo you have uthrna? Q QDo you have seasonal allergies that require medical treatment? Q Q

¥nNo

It is understood that, even though the athlete, whenever needed wears protective equipment, the possibility of an accident still remains.If, in the judgment of any representative of the school, the above athlete should need immediate care and treatment as a result of anyinjury or sickness, I do hereby request, authorize, and consent to such care and treatment as may be given said athlete by anyphysician, trainer or nurse. If, between this date and the beginning of athletic competition, any illness or injury should occur that mightlimit this athlete's participation, I agree to notify the athletic department or authorities of such illness or injury.Check any activity In which this student Is allowed to participate: Cl Baseball Cl Softball Cl TennisCl Basketball Cl Golf Cl Track & Field Cl Cross Country Cl Soccer Cl Team Tennis Cl Volleyball

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Athlete's Signature: __ __ Date: _~~~~~_