Patient:

:Last Name:

First Name:

Sex: Female Male

Grade: 9 10 11 12

Date:Sunday September 24, 2017

Date for treatment:

Phone (only numbers)

 Please answer the following questions to the best of your ability:
yes no don't know (1) Has anyone in the athlete's family died suddenly before the age of 50?

yes no don't know (2) Has the athlete ever passed out during exercise or stopped exercising because of dizziness or chest pain?

yes no don't know (3) Does the athlete have asthma (wheezing), hay fever, or coughing spells during or after exercise?

yes no don't know (4) Has the athlete ever broken a bone, had to wear a cast, or had an injury to any joint?

yes no don't know (5) Does the athlete have a history of a concussion (getting knocked out) or seizures?

yes no don't know (6) Has the athlete ever suffered a heart-related illness (heart stroke)?

yes no don't know (7) Does the athlete have a chronic illness or see a physician regularly for any particular problem?

yes no don't know (8) Does the athlete take any medicine?

yes no don't know (9) Is the athlete allergic to any medications or bee sting?

yes no don't know (10) Does the athlete have only one of any paired organs (eyes, ears, kidneys, testicles, ovaries, etc)?

yes no don't know (11) Has the athlete ever had prior limitation from sports participation?

yes no don't know (12) Has the athlete had any episodes of shortness of breath, palpitations, history of rheumatic fever or unusual fatigue?

yes no don't know (13) Has the athlete ever been diagnosed with a heart murmur, a heart condition, or hypertension?

yes no dont know (14) Is there a history of young people in the athlete's family who have had congenital or other heart disease: cardiomyopathy, abnormal heart rhythms, long QT or Marfan's syndrome?

yes no don't know (15) Has the athlete ever been hospitalized over night or had surgery?

yes no don't know (16) Does the athlete lose weight regulalry to meet the requirements of his/her sport?

yes no don't know (17) Does the athlete have anything he/she wants to discusss with the physician?

yes no don't know (18) Does the athlete cough, wheeze, or have trouble breathing after activity?

yes no don't know (19) Does the athlete have asthma?

(20) FEMALES ONLY

a. When was your last menustrual period?

b. When was your most recent menstrual period?

c. What was the longest time between menstrual periods in the last year?

 

 

Comments and/or Questions

Please enter full name with date of birth

Patient's address

Patient's email

Patient's insurance Insurance Id/Subscriber #

 

 

 

 

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