department of athletics policies & procedures - UNC Wilmington ...

University of North Carolina Wilmington:
Screening Examination for New Student-Athletes 2010
Name Sport Date / /
Age Date of Birth / / UNCW ID# Sex: M F
Class: FR SO JR SR 5 th SR Cell Phone # ( )
Please answer the following questions. State “none” or “NA” if not applicable:
Current medications -- please list all prescriptions and over-the-counter medications:
Allergies to medications:
Current medical conditions/injuries being treated:
Past hospitalizations or surgeries? (year, reason):
Do you currently take or plan to take supplements such as protein, creatine, or others? If yes, please list:
Do you smoke or use tobacco products?
Have you ever had any of the following injuries or conditions? Please circle Y or N for each of the following
injuries or conditions. Please explain any “yes” answers in the space to the right
1
List date/details
Heat related illness/severe cramps/passing out during exercise in hot weather Y N
Lightheadedness/dizziness/fainting or chest pain with exercise Y N
Severe headaches or headaches brought on by exercise Y N
Recent problems keeping up with teammates in sports Y N
Absence/loss of a paired organ (eye, kidney, testicle) Y N
Diabetes Y N
High blood pressure Y N
Kidney disease Y N