Upper Iowa University Sport:______

Upper Iowa University Athletic Training

MEDICAL HISTORY

Personal Data

Name: ______Last First Middle

Home Address: ______Street Address City State Zip

School Address: ______Street Address City State Zip

Home Phone #: ______School Phone #: ______Cell Phone #: ______

Social Security #: ______Date of Birth: ______(MM/DD/YYYY) Gender: ______Year in School: ______Sport(s): ______

In Case of Emergency, Notify:

Name: ______Relationship: ______Last First

Home Address: ______Street Address City State Zip

Home Phone #: ______Work Phone #: ______Cell Phone #: ______

General Medical History Current Medications/Supplements: Prescription and over-the-counter.

1. ______4. ______

2. ______5. ______

3. ______6. ______

Immunization: Most recent.

Tetanus: ______MMR: ______(MM/DD/YYYY) (MM/DD/YYYY) HBV: ______Other: ______(MM/DD/YYYY) (MM/DD/YYYY)

Family History: Has anyone in your immediate family had? YES NO Please Explain: Sudden Death (Before 50) Heart Disease/Heart Attack Heart Murmur Abnormal Heart Rate/Palpitation High Blood Pressure/Hypertension Diabetes Marfan Syndrome Epilepsy

1 Blood Disorder

Personal Medical History: Have you ever had/currently have any of the following conditions? YES NO ADD/ADHD Anemia/Low Blood Counts Appendicitis Asthma/Breathing Problems If you have an inhaler please bring an extra to the athletic trainer Chicken Pox Constipation/Diarrhea/Hemorrhoids Diabetes Eating Disorder (anorexia, bulimia) Emotional Disturbance (Depression / Anxiety) Epilepsy/Seizure Disorder Hearing Impairment/Loss Hernia Hepatitis/Liver Problems/Jaundice Kidney Disease/Stones/Injury Migraine/Headaches YES NO Missed a game due to illness Menstrual Irregularities Mononucleosis Pins/Staples/Wires/Screws in body Pneumonia/Frequent Respiratory Infections Recurrent Ear Infections Sexually Transmitted Disease Sickle Cell Disease Sickle Cell Trait Sinus Infection/Nasal Polyps/Nose Fracture Spleen/Liver Injury Stomach Problems (bleeding, ulcers) Stress Fracture Thyroid Disorder Tuberculosis Tumor/Growth/Cyst Urinary Problems (blood, recurrent infections) Human immunodeficiency virus (HIV)

2 Please Explain: ______

Internal/Surgical History: YES NO Were you born WITHOUT a complete set of organs (eyes, kidneys, ovaries/testes, etc…)? Have you ever had to repair / remove any organ (hernia, tonsils, appendix, spleen, etc…)? Please Explain: ______

Allergies: YES NO Penicillin Aspirin/Anti-Inflammatories YES NO Codeine Sulfa Hay Fever Any Foods Insect Stings/Bites Other Latex If you have an epi-pen please bring an extra to the athletic trainer Please Explain: ______

Cardiac History: Have you ever had/currently have any of the following conditions? YES NO High blood pressure/Hypertension Irregular heart beat/Palpitations Felt dizzy/Light-headed/Passed out during or after exercise? Chest pain/Tightness/Discomfort with exercise? Exertional shortness of breath YES NO Have seen a cardiologist? Rheumatic heart disease Had an echocardiogram/EKG? Had a stress test? Heart Murmur Easily fatigued

Heat Illness History: Have you ever? YES NO YES NO Become dehydrated? Had heat stroke? Had heat cramps? Received IV fluids? Had heat exhaustion? Had intolerance to heat? Please Explain: ______

Vision History: Have you ever/do you currently: Dental History: Have you ever/do you currently: YES NO YES NO Had an eye injury? Had a tooth knocked out/loose/chipped? Wear glasses/contacts/protective eyewear? Wear a dental appliance? If YES, please bring prescription and extra Wear a protection device? contacts to the athletic trainer Please Explain: ______Please Explain: ______

Please describe below any further general medical injury information, which is knowledgeable to you and has not been requested. ______

Orthopedic History Head Injury: Have you ever had/currently have: YES NO YES NO Concussion Hospitalization/Surgery Knocked out/Unconscious X-ray/CT/MRI Recurrent headaches/Migraines Missed practice/game time Fracture Other Please Explain: ______

Cervical Spine/Neck: Have you ever had/currently have: YES NO YES NO Injury/Sprain/Strain Unexplained weakness in arms or legs Disc injury Hospitalization/Surgery Pinched nerve/Stinger X-ray/CT/MRI/Bone Scan Fracture/Dislocation Missed practice/game time Numbness/Tingling/Burning in arms or legs Other Please Explain: ______

Shoulder/Upper Arm: Have you ever had/currently have: YES NO YES NO Injury/Sprain/Strain Unexplained weakness Bursitis/Tendinitis Hospitalization/Surgery Fracture/Dislocation/Subluxation X-ray/CT/MRI/Bone Scan Shoulder Separation Missed practice/game time Numbness/Tingling/Burning Other Please Explain: ______

Elbow/Forearm: Have you ever had/currently have:

4 YES NO Injury/Sprain/Strain

5 Bursitis/Tendinitis Fracture/Dislocation

6 Hospitalization/Surgery Numbness/Tingling/Burning YES NO Unexplained weakness X-ray/CT/MRI/Bone Scan Missed practice/game time Other

Wrist/Hand/Finger: Have you ever had/currently have: YES NO Injury/Sprain/Strain Brace/Cast/Splint Fracture/Dislocation Hospitalization/Surgery Numbness/Tingling/Burning YES NO Unexplained weakness X-ray/CT/MRI/Bone Scan Missed practice/game time Other

Spine/Low Back: Have you ever had/currently have: YES NO YES NO Injury/Sprain/Strain Unexplained weakness in leg Nerve/Disk Injury Hospitalization/Surgery Numbness/Tingling/Burning in leg X-ray/CT/MRI/Bone Scan Pain in leg Missed practice/game time Fracture/Dislocation Other Please Explain: ______

Ribs/Chest: Have you ever had/currently have: YES NO YES NO Injury/Sprain/Strain Unexplained weakness Fracture/Dislocation X-ray/CT/MRI/Bone Scan Hospitalization/Surgery Missed practice/game time Numbness/Tingling/Burning Other Please Explain: ______

Hip/Groin: Have you ever had/currently have: YES NO Injury/Sprain/Strain Bursitis/Tendinitis Fracture/Dislocation Hospitalization/Surgery Numbness/Tingling/Burning YES NO Unexplained weakness X-ray/CT/MRI/Bone Scan Missed practice/game time Other

Thigh: Have you ever had/currently have: YES NO YES NO Injury/Sprain/Strain Unexplained weakness Fracture X-ray/CT/MRI/Bone Scan Hospitalization/Surgery Missed practice/game time Numbness/Tingling/Burning Other Please Explain: ______

Knee: Have you ever had/currently have: YES NO Injury/Sprain/Strain Bursitis/Tendinitis Fracture/Dislocation/Subluxation Torn cartilage/Meniscal injury Swelling Locking/Giving away Numbness/Tingling/Burning YES NO Unexplained weakness Brace/Cast/Splint Hospitalization/Surgery X-ray/CT/MRI/Bone Scan Missed practice/game time Other

Ankle/Lower Leg: Have you ever had/currently have: YES NO YES NO Injury/Sprain/Strain Unexplained weakness Bursitis/Tendinitis Brace/Cast/Splint Fracture/Dislocation Hospitalization/Surgery Instability X-ray/CT/MRI/Bone Scan Stress Fracture/Shin Splints Missed practice/game time Numbness/Tingling/Burning Other Please Explain: ______

Foot/Toe: Have you ever had/currently have: YES NO YES NO Injury/Sprain/Strain Numbness/Tingling/Burning Bursitis/Tendinitis Hospitalization/Surgery Fracture/Dislocation X-ray/CT/MRI/Bone Scan Unexplained weakness Missed practice/game time Brace/Cast/Splint Other Please Explain: ______

Please describe below any further general medical injury information, which is knowledgeable to you and has not been requested. ______

The undersigned, hereby:

1. Affirm that all answers and information are correct and true, and that no answers or information have been withheld. 2. Understand that his/her having passed the physician examination does not necessarily mean he/she is physically qualified to engage in athletics, but only that the examiner did not find any medical reason to disqualify him/her. 3. Fully realize Upper Iowa University Athletic Department cannot be held responsible for any previous medical condition(s) he/she might have.

______Student-Athlete Printed Name

______Student-Athlete Signature Date

If under 18, a parent/guardian must sign as well.

______Parent / Guardian Printed Name

______Parent / Guardian Signature Date 11 12