DCSD
 
Athletic/Activity Medical Information
Student’s Name
: __________________________________
Birth Date
: ___________
_ Sex
:
M F
Year in School: 9
th
___ 10
th
___ 11
th
___ 12
th
___
Sport (s):______________________________________
_
 
Allergies:
(include medication, food, latex or other allergies):
_
 
_______________
_
______________
_
______________
_
Medications
(List ALL you are currently taking, including birth control pills):
_
 
_______________
_
______________
_
______________
_
Date of last Tetanus shot: _____________________
_
List any body piercing you have other than on your ears: ______________________
_
List any surgeries you have had and the approximate
date(s):________________________________________
__________________________________________________________________________________________
**
Please answer the following questions carefully and as accurately as possible. If you answer yes to any
question, please provide the date of occurrence and the care that was received**
Concussion History: It is extremely important that this be honest and accurate.
How many and when? _______________________________________________________________________
Did you lose consciousness? Yes____ No ____ Did you require care by a doctor? Yes____ No____
Have you ever been told by a doctor that you could not participate in a practice or game following a
concussion? Yes __ No____
Have you ever been advised by a doctor to wear protective head gear during sports? ______________________
Do you wear any type of protective head gear during sports? _________________________________________
YES
NO
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?
Has anyone in your family died of heart problems before 50?
Do you have any skin problems (itching, rashes, acne)?
Have you ever had heat or muscle cramps?
Have you ever had a stinger, burner or pinched nerve?
Have you ever been dizzy or passed out in the heat?
Do you have any special equipment (braces, mouth or eye guards)?
Please answer the following:
Have you ever had an injury or a fracture to any of the following:
YES
NO
1.
 
Head/neck
When/Treatment__________________________________
2.
 
Spine
When/Treatment__________________________________
3.
 
Shoulder(s)
When/Treatment__________________________________
4.
 
Elbow
When/Treatment__________________________________
5.
 
Wrist
When/Treatment__________________________________
6.
 
Hand
When/Treatment__________________________________
7.
 
Hip
When/Treatment__________________________________
8.
 
Knee
When/Treatment__________________________________
9.
 
Ankle
When/Treatment__________________________________
10.
 
Foot
When/Treatment__________________________________
(page 2)
Have you ever had any of the following:
YES
NO
1.
 
Diabetes
When/Treatment____________________________
_
 
If yes, are you insulin dependent:
When/Treatment____________________________
2.
 
Bladder or kidney infections
When/Treatment____________________________
3.
 
Mono
When/Treatment____________________________
4.
 
Hepatitis
When/Treatment____________________Type____
5.
 
Irritable bowel, colitis,
or Crohn disease
When/Treatment____________________________
6.
 
Collapsed lung
When/Treatment____________________________
7.
 
Asthma
When/Treatment____________________________
_
 
If yes, do you use an
inhaler/nebulizer
(circle)
8.
 
Chronic cough
When/Treatment____________________________
9.
 
Trouble Breathing or
Coughing during exercise
When/Treatment____________________________
10.
 
Heart murmur
When/Treatment____________________________
11.
 
High blood pressure
When/Treatment____________________________
12.
 
Racing or skipped heart beats
When/Treatment____________________________
13.
 
Ear infections
When/Treatment____________________________
14.
 
Eye infections
When/Treatment____________________________
15.
 
Glasses/contacts
When/Treatment____________________________
_
 
If yes to contacts,
When/Treatment____________________________
Do you wear hard or soft lenses?
Hard
Soft
(circle)
16.
 
Hearing impairment
When/Treatment____________________________
17.
 
Thyroid or adrenal disorder
When/Treatment____________________________
18.
 
Blood or clotting disorder
When/Treatment____________________________
19.
 
Anemia
When/Treatment____________________________
20.
 
Seizure or epilepsy
When/Treatment____________________________
21.
 
Dizziness
When/Treatment____________________________
22.
 
Recurrent headaches
When/Treatment____________________________
23.
 
Migraines
When/Treatment____________________________
Females Only:
Date of first menstrual period: _________________________________________________________________
Do you ever miss your periods: ________________________________________________________________
Please print your name: ______________________________________________________________________
Signature: _________________________________________________________Date:___________________
3/05