2.Have you ever had, or do you currently have, any of the following head-related conditions:
a. Concussion or head injury (including “bell rung” or a “ding”)? |
Y / N / Don’t Know |
b. Memory loss? |
Y / N / Don’t Know |
c. Knocked out? |
Y / N / Don’t Know |
c. A seizure? |
Y / N / Don’t Know |
d. Frequent or severe headaches (With or without exercise)? |
Y / N / Don’t Know |
e. Fuzzy or blurry vision |
Y / N / Don’t Know |
f. Sensitivity to light/noise |
Y / N / Don’t Know |
Explain all “yes” answers here (include relevant dates):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
3.Have you ever had, or do you currently have, any of the following heart-related conditions:
a. Restriction from sports for heart problems? |
Y / N / Don’t Know |
b. Chest pain or discomfort? |
Y / N / Don’t Know |
c. |
Heart murmur? |
Y / N / Don’t Know |
d. |
High blood pressure? |
Y / N / Don’t Know |
e. |
Elevated cholesterol level? |
Y / N / Don’t Know |
f. |
Heart infection? |
Y / N / Don’t Know |
g. |
Dizziness or passing out during or after exercise without known cause? |
Y / N / Don’t Know |
h.Has a provider ever ordered a heart test ( EKG, echocardiogram, stress test, Holter monitor)? Y / N / Don’t Know
i. |
Racing or skipped heartbeats? |
Y / N / Don’t Know |
j. |
Unexplained difficulty breathing or fatigue during exercise? |
Y / N / Don’t Know |
k.Any family member (blood relative):
(1.) |
Under age 50 with a heart condition? |
Y / N / Don’t Know |
(2.) |
With Marfan Syndrome? |
Y / N / Don’t Know |
(3.) |
Died of a heart problem before age 50? If yes, at what age? _____________________ |
Y / N / Don’t Know |
(4.) |
Died with no known reason? |
Y / N / Don’t Know |
(5.) |
Died while exercising? If yes, was it during or after? (Circle one.) |
Y / N / Don’t Know |
Explain all “yes” answers here (include relevant dates):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
4.Have you ever had, or do you currently have, any of the following eye, ear, nose, mouth or throat conditions:
a. Vision problems? |
Y / N / Don’t Know |
(1.) Wear contacts, eyeglasses or protective eye wear? (Circle which type.) |
Y / N / Don’t Know |
b. Hearing loss or problems? |
Y / N / Don’t Know |
(1.) Wear hearing aides or implants? |
Y / N / Don’t Know |
c. Nasal fractures or frequent nose bleeds? |
Y / N / Don’t Know |
d. Wear braces, retainer or protective mouth gear? |
Y / N / Don’t Know |
e. Frequent strep or any other conditions of the throat (e.g. tonsillitis)? |
Y / N / Don’t Know |
Explain all “yes” answers here (include relevant dates):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
5.Have you ever had, or do you currently have, any of the following neuromuscular/orthopedic conditions:
a. Numbness, a “burner”, “stinger” or pinched nerve? |
Y / N / Don’t Know |
b. |
A sprain? |
Y / N / Don’t Know |
c. |
A strain? |
Y / N / Don’t Know |
d. |
Swelling or pain in muscles, tendons, bones or joints? |
Y / N / Don’t Know |
e. |
Dislocated joint(s)? |
Y / N / Don’t Know |
f. |
Upper or lower back pain? |
Y / N / Don’t Know |
g. |
Fracture(s), stress fracture(s), or broken bone(s)? |
Y / N / Don’t Know |
h. |
Do you wear any protective braces or equipment? |
Y / N / Don’t Know |
Explain all (yes) answers here (include relevant dates):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Part A Page 2 of 3