Northwest Christian University Athletic Medicine New Student-Athlete Health

History

Student-Athlete Name Date This form is to be completed and signed by the athlete or, if athlete is under 18, by the athlete’s parent or legal guardian. Please fill out

prior to your physical examination and present to your provider for review

Provider: Please review with the athlete details of any “yes” answers and sign below

Family History — explain any "yes" answers

Has any member of your family:

Yes No Died suddenly? Who?

Yes No Had diabetes? Who?

Yes No Had heart problems? Who?

Yes No Had sickle cell anemia or sickle cell trait? Who?

Yes No Had depression or bipolar disorder? Who?

Personal Student-Athlete Medical History — explain any "yes" answers

Yes No *Do you regularly use any medications (prescription or over-the-counter)?

Yes No Do you have any medication allergies?

Yes No Do you have seasonal or food allergies?

Yes No Do you have asthma/wheezing?

Yes No Have you ever used an inhaler?

Yes No When exercising in hot environments, do you have severe muscle cramps or become ill?

Yes No *Have you ever been told you have anemia, low iron or sickle cell trait

Yes No Do you worry about your weight?

Yes No Do you currently think you need to lose weight?

Yes No Have you ever been diagnosed with an eating disorder?

Yes No Do you make yourself sick because you feel uncomfortably full?

Yes No Do you worry you have lost control over how much you eat?

Yes No Have you recently lost more than 15 lbs in the last three months?

Yes No Do you believe yourself to be fat when others say you are too thin

Yes No Would you say food dominates your life?

Yes No Have you ever been hit in the head and become confused?

Yes No Have you had a concussion?

Yes No Have you had chronic rashes or skin disease?

Yes No Have you ever had problems with your kidneys or liver?

Yes No Do you have a digestive tract disease or a hernia?

Yes No Were you born without or are you missing a kidney, eye, or testicle?

Yes No Do you have migraine headaches?

Yes No Have you had chest pain or unusual shortness of breath during exercise?

Yes No Have you ever fainted or passed out during exercise

Yes No *Do you have a heart murmur or other heart condition?

Yes No *Have you ever had an EKG, echocardiogram, or other heart test?

Yes No *Do you have high blood pressure or elevated cholesterol?

Yes No Have you had mononucleosis (mono)?

Yes No Have you ever had a sexually transmitted infection or HIV?

Yes No Have you or a member of your family ever had a blood clot?

Yes No Do you have diabetes or thyroid disease?

Yes No Do you have any hearing or vision problems?

Yes No Do you drink alcohol? If yes, how much and how often?

Yes No Do you use nicotine? If yes, how much and how often?

Yes No Do you now or have you ever used any supplements or performance enhancing substances

Yes No you have ADD or ADHD?

Yes No Have you ever seen a doctor or counselor for feeling depressed or anxious

*Orthopedic Injury History

Yes No Neck injuries (pinched nerves, stingers, sprain, etc.)

Yes No Back / chest / rib injuries (surgery, sprains, fractures, etc.)

Yes No Shoulder Injuries (Dislocation, separation, fracture, etc.)

Yes No Arm/wrist/hand/finger injuries (surgery, sprains, fractures, etc.)

Yes No Hip and pelvis injuries (surgery, sprains, fractures, etc.)

Yes No Knee injuries (Surgery, sprains, fractures, etc.)

Yes No Ankle Injuries (Surgery, sprains, fractures, etc.)

Yes No Foot Injuries (Surgery, sprains, fractures, etc.)

Yes No Chronic Muscle strains

Yes No Have you ever had an MRI or CT scan?

Yes No Have you ever had an x-ray or bone scan?

Yes No Do you have a history of stress fracture or stress reaction?

Medical Participation Questionnaire

Yes No Have you ever been held out of practice/competition for medical reasons?

Yes No Have you ever been hospitalized or had surgery?

Yes No Do you know any health reason that would inhibit your current ability to participate in intercollegiate athletics?

Females only

Yes No Have you ever had a menstrual period? Age periods started?

How many periods have you had in the past year?

Student Athlete Signature Date

Parent Signature Date

Signature of Provider Date

*Please have any associated medical records forwarded to NCU Athletic Training 828 E. 11th Avenue, Eugene OR

97401 or Fax 541-684-7317