INSTRUCTIONS: Page 1 of 6
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1 INSTRUCTIONS: 1. Medical History Form is to be completed by parent or legal guardian. 2. Fill out Medical History Form completely. Answer all questions correctly with as much detail as possible. Use back of form if necessary. 3. Athlete and parent/guardian must sign and date form. 4. Take completed Medical History Form to physical examination. Physician must review completed form. Page 1 of 6
2 Cowley County Community College Athletic Department Medical History Form Medical History to be filled out by parent/guardian and reviewed by physician. All questions are to be answered fully. Incomplete/illegible forms will result in athlete being unable to participate in Any team activity until completed. PLEASE CLEARLY PRINT ALL INFORMATION IN BLACK INK Full Name Date Sport(s) DOB SS# Sex Year in College ATHLETE MEDICAL HISTORY Answer the following questions by checking YES or NO. If you answer Any question YES, please give a detailed explanation including anatomical site, date, left or right, frequency, surgery, treatment, physical therapy and Any other important data. If you have a condition not listed, please comment at the end of list. General Medical Diseases and Illnesses YES NO Comments Use Alcohol, How Often ( ) ( ) Anemia ( ) ( ) Any Reason Why Athlete Should Not ( ) ( ) Participate in Athletics Appendicitis ( ) ( ) Arthritis ( ) ( ) Asthma ( ) ( ) Bleed or Bruise Easily ( ) ( ) Cancer, Tumor, Growth, or Cyst ( ) ( ) Chronic or Ongoing Illness ( ) ( ) Circulatory Problems ( ) ( ) Currently Under a Physician s Care For Any ( ) ( ) Reason Diabetes ( ) ( ) During/After Exercise Experienced Dizziness, ( ) ( ) Lightheadedness or Loss of Consciousness During/After Exercise Experienced Chest Pain, ( ) ( ) Palpitations, Skipped a Beat, Racing Heart During/After Exercise Been Out of Breath, ( ) ( ) Trouble Breathing, Wheezing Eating Disorder(s)- Anorexia, Bulimia, Etc. ( ) ( ) Epilepsy, Seizures, or Convulsions ( ) ( ) Ever Used Tobacco, Cigarettes, Steroids, ( ) ( ) Supplements, Creatine, Weight Loss Meds, Laxatives Fatigue, Unexplainable or Excessive ( ) ( ) Frequent Diarrhea ( ) ( ) Frequent Headaches ( ) ( ) Frequent Migraines ( ) ( ) Frequent Sore Throats ( ) ( ) Frequent Colds ( ) ( ) Frequent or Painful Urination ( ) ( ) Heart Murmur, Disease, Disorder ( ) ( ) Heat Illness, Intolerance, or Cramps ( ) ( ) Hemorrhoids ( ) ( ) Hepatitis ( ) ( ) Hernia ( ) ( ) High Blood Pressure ( ) ( ) High Blood Cholesterol ( ) ( ) HIV/AIDS ( ) ( ) Page 2 of 6
3 General Medical Diseases and Illnesses YES NO Comments Hospitalized for Any Reason ( ) ( ) Hypo/Hyperglycemia ( ) ( ) Use an Inhaler ( ) ( ) Jaundice ( ) ( ) Kidney or Bladder Dysfunction/Disease ( ) ( ) Loss of Function/Removal of Any Paired Organ ( ) ( ) Mental Illness/Depression/Anxiety/Insomnia ( ) ( ) Mononucleosis ( ) ( ) Night Sweats ( ) ( ) Organ(s) Removed ( ) ( ) Pneumonia ( ) ( ) Rheumatic Fever ( ) ( ) Scarlet Fever ( ) ( ) Sickle Cell Anemia/Trait ( ) ( ) Skin Problems- Acne, Rashes, Eczema, ( ) ( ) Fungus, Herpes, Warts, etc. Spleen, Liver, or Gallbladder Problems ( ) ( ) Sexually Transmitted Disease(s) ( ) ( ) Stomach Disorder(s) ( ) ( ) Surgeries/Operations ( ) ( ) Tuberculosis ( ) ( ) Unequal Pupils ( ) ( ) Understand All of These Questions ( ) ( ) Vegetarian ( ) ( ) Viral/Bacterial Infection in Last 12 Months ( ) ( ) Weight Loss or Gain of 10lb. or More in ( ) ( ) Last 12 Months Withheld From Sports for Any Reason ( ) ( ) Dental Eyes Hearing and Facial YES NO Comments Dentures, Partials, Retainers, Braces ( ) ( ) Dental Exam in Last 12 Months ( ) ( ) Eye Exam in Last 12 Months ( ) ( ) Hearing Loss, Hearing Aid ( ) ( ) Ringing in Ears ( ) ( ) Impaired Vision ( ) ( ) Glasses/Contacts- What Type ( ) ( ) Sight in Both Eyes ( ) ( ) Fractured Facial Bones- Nose, Jaw, etc. ( ) ( ) Muscle Bone and Joint YES NO Comments Fracture of Any Bone in Last 3 years ( ) ( ) Strain of Any Muscle or Tendon ( ) ( ) Limited Range of Motion in Any Joint ( ) ( ) Pins, Screws, or Plates Anywhere in ( ) ( ) Your Body Use Any Special Equipment- Braces, ( ) ( ) Mouthpiece, etc. Pain or Swelling in Any Body Part ( ) ( ) Had Shin Splints More Than Once ( ) ( ) Diagnosed with Scoliosis ( ) ( ) Sprain, Fracture, Dislocation of Foot/Toes ( ) ( ) Foot/Toe Injury- Muscle, Tendon, Ligament, ( ) ( ) Physical Therapy for Foot/Toe ( ) ( ) Advised to Have Surgery for Foot/Toe ( ) ( ) Surgery to Correct Foot/Toe ( ) ( ) Page 3 of 6
4 Muscle Bone and Joint YES NO Comments Sprain, Fracture, Dislocation of Ankle ( ) ( ) Ankle Injury- Muscle, Tendon, Ligament, ( ) ( ) Physical Therapy for Ankle ( ) ( ) Advised to Have Surgery to Correct Ankle ( ) ( ) Surgery to Correct Ankle ( ) ( ) Sprain, Fracture, Dislocation of Knee ( ) ( ) Knee Injury- Muscle, Tendon, Ligament, ( ) ( ) Physical Therapy for Knee ( ) ( ) Advised to Have Surgery to Correct Knee ( ) ( ) Surgery to Correct Knee ( ) ( ) Sprain, Fracture, Dislocation of Hip ( ) ( ) Hip Injury- Muscle, Tendon, Ligament, ( ) ( ) Physical Therapy for Hip ( ) ( ) Advised to Have Surgery to Correct Hip ( ) ( ) Surgery to Correct Hip ( ) ( ) Sprain, Fracture, Dislocation of Pelvis ( ) ( ) Pelvic Injury- Muscle, Tendon, Ligament, ( ) ( ) Physical Therapy for Pelvic ( ) ( ) Advised to Have Surgery to Correct Pelvic ( ) ( ) Surgery to Correct Pelvic ( ) ( ) Sprain, Fracture, Dislocation of Spine ( ) ( ) Spinal Injury- Muscle, Tendon, Ligament, ( ) ( ), Disk Physical Therapy for Spinal ( ) ( ) Advised to Have Surgery to Correct Spinal ( ) ( ) Surgery to Correct Spinal ( ) ( ) Experience Pain in Your Back, list frequency ( ) ( ) Injured Your Back ( ) ( ) Sprain, Fracture, Dislocation of Shoulder ( ) ( ) Shoulder Injury- Muscle, Tendon, Ligament, ( ) ( ) Physical Therapy for Shoulder ( ) ( ) Advised to Have Surgery to Correct Shoulder ( ) ( ) Surgery to Correct Shoulder ( ) ( ) Sprain, Fracture, Dislocation of Elbow ( ) ( ) Elbow Injury- Muscle, Tendon, Ligament, ( ) ( ) Physical Therapy for Elbow ( ) ( ) Advised to Have Surgery to Correct Elbow ( ) ( ) Surgery to Correct Elbow ( ) ( ) Sprain, Fracture, Dislocation of Wrist ( ) ( ) Wrist Injury- Muscle, Tendon, Ligament, ( ) ( ) Physical Therapy for Wrist ( ) ( ) Advised to Have Surgery to Correct Wrist ( ) ( ) Surgery to Correct Wrist ( ) ( ) Page 4 of 6
5 Muscle Bone and Joint YES NO Comments Sprain, Fracture, Dislocation of Hand/Fingers ( ) ( ) Hand/Finger Injury- Muscle, Tendon, Ligament, ( ) ( ) Physical Therapy for Hand/Finger ( ) ( ) Advised to Have Surgery to Correct ( ) ( ) Hand/Finger Surgery to Correct Hand/Finger ( ) ( ) Ever Worn Special Brace or Made ( ) ( ) Modifications to Equipment Head and Neck Injuries YES NO Comments Skull Fracture ( ) ( ) Frequent Headaches or Migraines ( ) ( ) Unequal Pupils ( ) ( ) Concussion or Head Injury ( ) ( ) Hospitalized for Head Injury or Concussion ( ) ( ) Knocked Unconscious ( ) ( ) Memory Loss ( ) ( ) Neck Injury/Sprain, Strain, Fracture ( ) ( ) Hospitalized for Any Neck Injury ( ) ( ) Surgery of Any Kind on Head and/or Neck ( ) ( ) Burner or Stinger ( ) ( ) Experienced Pain/Numbness in Neck, ( ) ( ) Shoulder, and/or Hand Family History (Immediate Family Only) YES NO Comments Alcoholism/Drug Abuse ( ) ( ) Bleeding Disorder/Blood Disease ( ) ( ) Cancer ( ) ( ) Cardiovascular Disease ( ) ( ) Epilepsy ( ) ( ) Heart Disease ( ) ( ) Heart Trouble ( ) ( ) High Blood Pressure ( ) ( ) Marfan s Syndrome ( ) ( ) Mental Illness/Depression ( ) ( ) Sickle Cell Trait/Disease ( ) ( ) Stroke ( ) ( ) Suicide ( ) ( ) Sudden Death Before 50 Years of Age ( ) ( ) Tuberculosis ( ) ( ) Female Athletes YES NO Comments Abnormal Pap Smear ( ) ( ) Birth Control Pills ( ) ( ) Any Problems with Breast(s) ( ) ( ) Endometriosis ( ) ( ) Excessive Flow ( ) ( ) Pain Medication ( ) ( ) Pregnant ( ) ( ) Menstruation Absent, Painful, Irregular ( ) ( ) Age of Onset of Period Period Duration Interval Between Periods Number of periods in last 12 months Do You Understand These Questions ( ) ( ) Have You Answered All Questions Correctly ( ) ( ) Page 5 of 6
6 Male Athletes YES NO Comments Loss of Testicle ( ) ( ) Loss of Function of Testicle ( ) ( ) Injury to Testicle - Torsion, Hydrocele, ( ) ( ) Varicocele Do You Understand These Questions ( ) ( ) Have You Answered All Questions Correctly ( ) ( ) If you answered YES to any of the above questions and/or have any further information which is knowledgeable to you and not required on this form, please explain in detail (use additional sheet(s) if necessary. If you answered YES to any of the above conditions, has athlete been cleared to participate in athletics by his/her treating physician? I, the undersigned, hereby acknowledge, affirm, and represent that all above statements are true and accurate to the best of my knowledge, and that no answers or information have been withheld. If any information and or statements are false and/or have been omitted in reference to athlete s past and/or present medical history, I fully understand that Cowley County Community College, its agents, servants, trustees, and employees disclaim liability, and will not be held liable for any injuries and/or illnesses not noted. Parent/Guardian Signature Athlete Signature Date Date Page 6 of 6
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