HEALTH PHYSICAL FORM - Huntington University

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CURRENT and PAST MEDICAL HISTORY – Indicate which of the following apply to you: □ Abdominal pain □ Convulsion/seizure □ General weakness □ Kidney stones □ Pertussis (whooping □ Aching eyes □ Cough □ Glasses/contacts □ Loss of a digit cough) □ Anemia □ Curvature of spine □ Gout □ Loss of balance □ Pinched nerve □ Angina/chest pain □ Deafness □ Hay fever □ Loss of memory □ Pins, screws, plates □ Anorexia □ Decreased motion □ Headaches □ Loss of sensation □ Pneumonia □ Apnea □ Deformities □ Hearing loss □ Lyme’s disease □ Pregnancy □ Appendicitis □ Dental appliances □ Heart attack □ Marfan’s syndrome □ Profuse bleeding □ Arrhythmia □ Depression □ Heart disease □ Measles □ Rheumatic fever □ Arthritis □ Diabetic problems □ Heart murmur □ Migraines □ Ringing in ears □ Asthma attack □ Digestive problems □ Heart problems □ Missing organ pair □ Rubella □ Back/neck injuries □ Dizziness □ Heat illness □ Mononucleosis □ Shortness of breath □ Blackouts □ Drug abuse □ Hepatitis □ Motion sickness □ Sickle cell □ Bladder infection □ Easily bruised □ Hernia □ Mumps □ Skin problems □ Blindness □ Eating Disorder □ Hypertension □ Nausea/vomiting □ Sore throat □ Blood disorder □ Emphysema □ Impetigo □ Nerve damage □ Speech impaired □ Blood in urine □ Epilepsy □ Increased thirst □ Neuro disorder □ Stroke □ Blurred vision □ Fainting spells □ Influenza □ Nose bleeds □ Trouble breathing □ Cancer □ Feet problems □ Infrequent periods □ Pacemaker during exercise □ Change in hunger □ Frequent colds/flu □ Insomnia □ Painful joints □ Tuberculosis □ Chicken pox □ Frequent urination □ Irregular heartbeat □ Painful urination □ Ulcers □ Concussion □ Frost bite □ Kidney disease □ Persistent cough □ Weight loss or gain □ Gas reflux □ None Apply Explain all checked boxes with Dates of Treatment:_____________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Medical History Questionnaire Explain “Yes” answers: Yes No 1. Have you ever been denied/restricted in sports participation for any health reasons?....................................... □ □ Date: Illness/Condition: _________________ ___________________________________________________ 2. Have you ever sprained, strained, dislocated, fractured, broken or had repeated swelling or other injuries of □ □ any bones or joints?............................................................................................................................................ □ Head □ Neck □Back □Shoulder □Hip □Thigh □Knee □Shin/Calf □ Ankle □Foot □Elbow □Forearm □Wrist □Hand Date: Injury: Date Released: __________________ ____________________________________________________ __________________ __________________ ____________________________________________________ __________________ 3. Have you ever been hospitalized for a serious illness or injury?..................................................................... □ □ Date: Illness/Condition: Date Released: __________________ ____________________________________________________ __________________ __________________ ____________________________________________________ __________________ 4. Have you ever had surgery? ………………………………………………………………………………… □ □ Date: Surgeon: Procedure: Date Released __________________ __________________________ ________________________ __________________ __________________ __________________________ ________________________ __________________ 5. Are you presently under a doctor’s care? …………………………………………………………………... □ □ Explain any current illness or pre-existing medical conditions that could affect your participation: _______________________________________________________________________________________________ _______________________________________________________________________________________________ 6. Do you have any allergies? ………………………………………………………………………………… □ □ List all allergies (foods, medicine, bees or stinging insects, latex, iodine and anesthesia reactions): _______________________________________________________________________________________________ 2.
<strong>HEALTH</strong> HISTORY (continued) Yes No 7. Have you ever passed out during or after exercise? ……………………………………………………….. □ □ 8. Have you ever been dizzy during or after exercise? ……………………………………………………….. □ □ 9. Have you ever had discomfort, pain or pressure in your chest during or after exercise? ………………….. □ □ 10. Do you get more tired than your friends during exercise? ………………………………………………… □ □ 11. Have you had a severe viral infection (myocarditis or mononucleosis) within the last year? …………….. □ □ 12. Has anyone in your family died of heart problems or a sudden death before age 50? ……………………. □ □ 13. Has a physician ever ordered a test (ECG, echocardiogram) on your heart? ……………………………... □ □ 14. Is there anyone in your family that has asthma? …………………………………………………………… □ □ 15. Have you ever used an inhaler or taken asthma medicine? ………………………………………………… □ □ 16. Have you ever been knocked out or unconscious or lost your memory due to a head injury? …………….. □ □ 17. Have you ever had numbness, tingling, or weakness in your arms or lets after being hit or falling? ……… □ □ 18. Have you ever been unable to move your arms or legs after being hit or falling? …………………………. □ □ 19. Do you use any special equipment (pads, braces, neck rolls, eye guards, etc.)? …………………………… □ □ 20. Have you had any problems with your eyes or vision? …………………………………………………….. □ □ 21. Are you happy with your weight? …………………………………………………………………………... □ □ 22. Are you trying to gain or lose weight? ……………………………………………………………………… □ □ 23. Has anyone recommended you change your weight or eating habits? ……………………………………… □ □ 24. Do you limit or control what you eat? ………………………………………………………………………. □ □ 25. Has anyone in your family had Marfan’s syndrome? ……………………………………………………… □ □ 26. Have you ever had heat cramps, heat illness or muscle cramps? …………………………………………… □ □ 27. Are you missing an eye, kidney, testicle or ovary? ………………………………………………………… □ □ 28. Are you currently taking any medications/vitamins/herbal remedies for a particular medical condition? ….. □ □ Medication: ______________________________ Condition: ____________________________________________________ Explain any “Yes” answers to the above questions:___________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ 3.
Page 1: Allergies & Restrictions: _________
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HEALTH PHYSICAL FORM - Huntington University

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