Medical Health History Questionnaire - University of Texas at Dallas

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MEDICAL INFORMATION 2013-2014 I. Prescription Medications: Please List ALL Prescription & Over-the-Counter Medications That you are CURRENTLY taking and for what purpose: (please write “None” if you are not currently on any medication) MEDICATION PURPOSE DOSAGE DATE(S) YES NO Have you been diagnosed with Attention-deficit hyperactivity disorder? (ADHD) When were you diagnosed? __________________ YES NO If above answer is “YES”, are you currently taking prescription medication prescribed by your doctor for ADHD? Please list above. II. Medical Testing: Note*- If you do not know exact dates, approximate month/year will suffice Have you ever been tested for HIV/AIDS that you are aware of? YES NO ♦ Date(s) of Test(s)? Location(s) of Test(s) Have you ever contracted any type of Hepatitis? YES NO ♦ Date(s)? Treatment? Have you ever been tested for the Sickle Cell Trait, or told that you carry it? YES NO ♦ Date? Result? Does anyone in your immediate family have the Sickle Cell Trait or Anemia? YES NO t Who? _______________________________________ III. Heat Related Problems: Have You Ever Experienced (check all that apply): ♦ Heat Cramps- Date(s)? ♦ Heat Exhaustion- Date(s)? ♦ Heat Stroke- Date(s)? Have You Ever Received Intravenous Fluids (IV) For A Heat Related Problem? YES NO ♦ Date(s)? Have You Ever Been Hospitalized For a Heat-Related Problem? YES NO ♦ Date(s)? Where? If YES, do you regularly experience any of the following symptoms during or after exercise? Muscle Cramping YES NO Fatigue YES NO Dehydration YES NO Fainting/Passing Out YES NO UTD ATHLETIC TRAINING 2 of 8
2013-2014 IV. Allergies: Have You Ever Been Diagnosed With Any Allergies? YES NO ♦ Please Describe Are You Presently Taking/Have You Previously Taken Any Allergy Medications? YES NO ♦ Please Describe Are you allergic to and/or ever had an unfavorable / allergic reaction to any medications? YES NO ♦ Please Describe Are you allergic to and/or ever had an unfavorable / allergic reaction to any food items? YES NO ♦ Please Describe Are you allergic to and/or ever had an unfavorable / allergic reaction to bee stings, insect bites, etc.? YES NO ♦ Please Describe V. Asthma: Have You Ever Been Diagnosed With Asthma and/or Exercised Induced Asthma? YES NO ♦ Date(s)? ♦ Please Describe Are You Presently Taking / Have You Previously Taken Any Asthma Medications / Use an Inhaler? YES NO ♦ Date(s)? ♦ Please Describe How Many Acute Asthma Attacks Have You Had In The Past 24 Months? ♦ Date(s)? ♦ Please Describe VI. Eyes: Do you have any eye conditions or diseases? YES NO t Please Describe______________________________________________________________________________________ Do you routinely wear glasses or contact lenses? YES NO ♦ What Type? Do you require any special devices / equipment? (i.e. goggles) YES NO ♦ Please Describe VII. Diabetic History: Have You Ever Been Diagnosed With Diabetes? YES NO ♦ Date Diagnosed? Are You Presently Taking or Have You Taken Any Diabetic Medications? YES NO Medication Form Dosage Frequency Do You “Daily” Monitor Your Blood Sugar Level? YES NO ♦ Please Describe Please List Any Precautions That You Take and/or Additional Information Not Mentioned Above: UTD ATHLETIC TRAINING 3 of 8
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Medical Health History Questionnaire - University of Texas at Dallas

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