Mhsaa Medical Form – Fill Out and Use This PDF

MEDICAL HISTORY

• To

e

o pleted

y pare t or guardia

or 18-year-old.

• Must

e sig ed below by parent or guardian or 18-year-old.

A CURRENT-YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR

LAST

FIRST

MI

SEX

GRADE

DATE OF BIRTH

AGE

STUDENT’S NAME:

---

---

NUMBER AND STREET

CITY

ZIP

STUDENT’S ADDRESS:

NAME OF FATHER OR GUARDIAN

WORK PHONE

NAME OF MOTHER OR GUARDIAN

WORK PHONE

FAMILY DOCTOR

OFFICE PHONE

STUDENT’S HOME PHONE

MEDICAL HISTORY

GENERAL QUESTIONS

YES

NO

YOUR FAMILY’S

HEART HEALTH QUESTIONS

YES

NO

MEDICAL QUESTIONS

YES

NO

Has a Doctor ever denied or restricted your participation in

Does anyone in your family have arrhythmogenic

Do you have any concerns that you would like to

Sports for any reason?

right ventricular cardiomyopathy, long QT syndrome?

discuss with a doctor?

Do you have any ongoing medical conditions? If so, please

Has any family member or relative died of heart

Were you born without or are you missing an organ?

Problems or had an unexpected or unexplained sudden

Identify by Circling: Asthma

Anemia Diabetes

Identify by circling: A kidney An eye

Your spleen

death before age 50 (including drowning, unexplained

Infections

Other: ________________

A testicle (males)

Any other organ? _____________

car accident or sudden infant death syndrome) ?

Have you ever spent the night in the hospital?

Does anyone in your family have catecholaminergic

Have you ever had an eating disorder?

polymorphic ventricular tachycardia, short QT syndrome?

Have you ever had surgery?

Do you worry about your weight?

HEART HEALTH QUESTIONS ABOUT YOU

YES

NO

BONE AND JOINT QUESTIONS

YES

NO

Have you ever had a head injury or concussion?

Have you ever passed out or nearly passed out DURING

Have you ever had an injury to a bone, muscle, ligament

Have you ever had a hit or blow to the head that caused

or after exercise?

or tendon that caused you to miss a practice or a game?

confusion, prolonged headache, or memory problems?

Have you ever had discomfort, pain, tightness or pressure

Have you ever had any broken or fractured bones or

Have you ever had numbness, tingling, or weakness in

in your chest during exercise?

dislocated joints?

your arms or legs after being hit or falling?

Do you get lightheaded or feel more short of breath than

Have you ever had an injury that required x-rays, MRI,

Have you ever been unable to move your arms or legs

expected during exercise?

CT scan, injections, therapy, a brace or cast or crutches?

after being hit or falling?

Do you get more tired or short of breath more quickly than

Have you ever been told that you have neck instability or

Are you trying to or has anyone recommended that you

your friends during exercise?

atlantoaxial instability (Down syndrome or dwarfism)?

gain or lose weight?

Has a doctor ever ordered a test for your heart?

Have you ever had an x-ray for neck instability or

Are you on a special diet or do you avoid certain

For example: ECG/EKG, echocardiogram

atlantoaxial instability (Down syndrome or dwarfism)?

types of foods?

Have you ever had an unexplained seizure or do you have

Do you regularly use a brace, orthotics, or other assistive

Do you wear protective eyewear, such as goggles, or a

a history of seizure disorder?

device?

face shield?

Does your heart ever race or skip beats (irregular beat)

Do any of your joints become painful, swollen, feel warm

Do you or someone in your family have sickle cell trait

during exercise?

or look red?

or disease?

Has a doctor ever told you that you have high blood

Do you have any history of juvenile arthritis or

Have you had any problems with your eyes or vision

pressure?

connective tissue disease?

or had any eye injuries?

Has a doctor ever told you that you have high cholesterol?

Have you ever had a stress fracture?

Do you wear glasses or contact lenses?

Has a doctor ever told you that you have Kawasaki disease?

Have you a bone, muscle, or joint injury bothering you?

Have you ever had herpes or MRSA skin infection?

Has a doctor ever told you that you have other heart

Have you had infectious mononucleosis (mono) within

IMMUNIZATION HISTORY

YES

NO

problems?

the last month?

Has a doctor ever told you that you have a heart infection?

Are you missing any recommended vaccines (Tdap, Flu,

Do you have any rashes, pressure sores, or other skin

MCV4, HPV, Varicella, MMR)

problems?

Has a doctor ever told you that you have a heart murmur?

MEDICAL QUESTIONS

YES

NO

Do You Have Any Allergies?

YOUR FAMILY’S HEART HEALTH QUESTIONS

YES

NO

Have you ever become ill while exercising in the heat?

FEMALES ONLY

YES

NO

Does anyone in your family have a heart problem,

Do you cough, wheeze, or have difficulty breathing

Have you ever had a menstrual period?

Pacemaker, or implanted defibrillator?

during or after exercise?

Does anyone in your family have hypertrophic

Do you have headaches or get frequent muscle cramps

How old were you when you had your first

cardiomyopathy, Marfan syndrome, Brugada syndrome?

When exercising?

menstrual period?

Anyone in your family had unexplained fainting?

Do you have pain,

a painful bulge or hernia in the groin?

How many periods have you had in the last

Anyone in your family had unexplained seizures?

Is there any one in your family who has asthma?

twelve (12) months?

Anyone in your family had unexplained near drowning?

Have you ever used an inhaler or taken asthma medicine?

IN EMERGENCY

1) _________________________________ Phone #: ___________________ Cell #: ____________________

CONTACT

or 2) _______________________________ Phone #: ___________________ Cell #: ____________________