<p> Upper Iowa University Athletic Training</p><p>MEDICAL HISTORY</p><p>Personal Data</p><p>Name: ______Last First Middle</p><p>Home Address: ______Street Address City State Zip</p><p>School Address: ______Street Address City State Zip</p><p>Home Phone #: ______School Phone #: ______Cell Phone #: ______</p><p>Social Security #: ______Date of Birth: ______(MM/DD/YYYY) Gender: ______Year in School: ______Sport(s): ______</p><p>In Case of Emergency, Notify:</p><p>Name: ______Relationship: ______Last First </p><p>Home Address: ______Street Address City State Zip</p><p>Home Phone #: ______Work Phone #: ______Cell Phone #: ______</p><p>General Medical History Current Medications/Supplements: Prescription and over-the-counter.</p><p>1. ______4. ______</p><p>2. ______5. ______</p><p>3. ______6. ______</p><p>Immunization: Most recent.</p><p>Tetanus: ______MMR: ______(MM/DD/YYYY) (MM/DD/YYYY) HBV: ______Other: ______(MM/DD/YYYY) (MM/DD/YYYY)</p><p>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</p><p>1 Blood Disorder</p><p>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)</p><p>2 Please Explain: ______</p><p>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: ______</p><p>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: ______</p><p>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</p><p>3 Please Explain: ______</p><p>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: ______</p><p>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: ______</p><p>Please describe below any further general medical injury information, which is knowledgeable to you and has not been requested. ______</p><p>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: ______</p><p>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: ______</p><p>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: ______</p><p>Elbow/Forearm: Have you ever had/currently have:</p><p>4 YES NO Injury/Sprain/Strain</p><p>5 Bursitis/Tendinitis Fracture/Dislocation</p><p>6 Hospitalization/Surgery Numbness/Tingling/Burning YES NO Unexplained weakness X-ray/CT/MRI/Bone Scan Missed practice/game time Other</p><p>7 Please Explain: ______</p><p>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</p><p>8 Please Explain: ______</p><p>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: ______</p><p>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: ______</p><p>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</p><p>9 Please Explain: ______</p><p>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: ______</p><p>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</p><p>10 Please Explain: ______</p><p>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: ______</p><p>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: ______</p><p>Please describe below any further general medical injury information, which is knowledgeable to you and has not been requested. ______</p><p>The undersigned, hereby:</p><p>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.</p><p>______Student-Athlete Printed Name </p><p>______Student-Athlete Signature Date</p><p>If under 18, a parent/guardian must sign as well.</p><p>______Parent / Guardian Printed Name </p><p>______Parent / Guardian Signature Date 11 12</p>