Medical Health History Questionnaire - University of Texas at Dallas

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2013-2014 Thigh/Hamstrings/Quadriceps YES NO Have you ever suffered an injury to your thigh/hamstrings/quadriceps? YES NO Have you ever had any diagnostic tests performed on your thigh/hamstring/quadriceps? If yes, please circle all that apply: X-RAY MRI CT SCAN BONE SCAN OTHER _______________ YES NO Have you ever had surgery and/or an injection of any kind to your thigh/hamstring/quadriceps? YES NO Have you ever been advised not to participate in sports due to an injury to your thigh/hamstring/quadriceps? If yes to any of the above, please explain and provide dates below. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Knee/Patella YES NO Have you ever suffered an injury to your knee/patella? YES NO Have you ever had any diagnostic tests performed to your knee/patella? If yes, please circle all that apply: X-RAY MRI CT SCAN BONE SCAN OTHER _______________ YES NO Have you ever had surgery and/or an injection of any kind to your knee/patella? YES NO Have you ever been advised not to participate in sports due to a knee/patella injury? YES NO Do you wear a knee brace/sleeve? If yes to any of the above, please explain and provide dates below. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Ankle/Lower Leg YES NO Have you ever suffered an injury to your ankle/lower leg? YES NO Have you ever had any diagnostic tests performed to your ankle/lower leg? If yes, please circle all that apply: X-RAY MRI CT SCAN BONE SCAN OTHER _______________ YES NO Have you ever had surgery and/or an injection of any kind to your ankle/lower leg? YES NO Have you ever been advised not to participate in sports due to an injury to an ankle/lower leg? YES NO Do you presently tape your ankles regularly? YES NO Do you presently wear ankle braces? If yes to any of the above, please explain and provide dates below. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Foot/Toes YES NO Have you ever suffered an injury to your foot/toes? YES NO Have you ever had any diagnostic tests performed to your foot/toes? If yes, please circle all that apply: X-RAY MRI CT SCAN BONE SCAN OTHER _______________ YES NO Have you ever had surgery and/or an injection of any kind to your foot/toes? YES NO Have you ever been advised not to participate in sports due to an injury to a foot/toe? YES NO Do you currently wear orthotics? If yes to any of the above, please explain and provide dates below. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Ribs/Thorax/Chest YES NO Have you ever suffered an injury to your ribs/thorax/chest? YES NO Have you ever had any diagnostic tests performed to your ribs/thorax/chest? If yes, please circle all that apply: X-RAY MRI CT SCAN BONE SCAN OTHER _______________ YES NO Have you ever had surgery and/or an injection of any kind to your ribs/thorax/chest? YES NO Have you ever been advised not to participate in sports due to an injury to the ribs/thorax/chest? If yes to any of the above, please explain and provide dates below. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ UTD ATHLETIC TRAINING 6 of 8
2013-2014 Additional Orthopedic Concerns YES YES YES YES YES YES YES YES YES NO Have you ever been withheld or restricted from participation in sports due to an orthopedic injury, other than those listed above? NO Have you ever been restricted for a month or more from sports activity due to an orthopedic injury? NO Have you undergone surgery for an orthopedic injury, other than those listed previously? NO Have you suffered the same injury more than once? NO Do you routinely suffer from over-use injuries that resolve with rest, and recur as you exercise more frequently and/or at a higher intensity? NO Have you ever had a stress fracture anywhere in your body, not previously noted? If yes, have you had any recurring stress fractures in the same body part? NO Do you regularly where any type of brace, sleeve, wrap, or support, other than previously noted? NO Have you ever suffered a traumatic orthopedic injury as a result of an accident or other non-sports related activity that required medical attention? NO Do you currently have any orthopedic concerns you would like to discuss with a physician? Please explain any “YES” answers here and provide dates if possible. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ X. Please Answer: Explain “Yes” Answers below. (All questions are strictly CONFIDENTIAL) YES NO Have you ever been hospitalized overnight? YES NO Have you ever been told by a physician to restrict your physical activity or not to participate in a sport? YES NO Are you currently under a physician’s care for any medical conditions? (illnesses, injuries, surgeries, etc.) YES NO Have you ever been under the care of a psychiatrist and/or psychologist? YES NO Have you consulted and/or been under the care of a chiropractor, hypnotist, acupuncturist, massage therapist, spiritual healer, and/or other such practitioner in the past two (2) years? YES NO Have you ever had a rash or hives develop during and/or after exercise? YES NO Do you have any skin problems? (Staph, itching, rashes, acne, herpes, eczema, warts, fungus, or blisters) YES NO Do you cough, wheeze, or have trouble breathing during or after exercise / practice? YES NO Do you have only one of two paired, functioning organs (eyes, kidney, ovary, etc.)? YES NO Have you ever been told that you have kidney disease? YES NO Have you had a viral infection (i.e. mononucleosis, myocarditis, etc.) within the past six (6) months? YES NO Have you ever had seizures or convulsions? YES NO Do you have any hearing problems or other conditions of your ears? Ear Infections? Require hearing aid? YES NO Do you have any dental/mouth problems, conditions or diseases? False Teeth? Bridges? Etc? YES NO Do you have frequent nosebleeds? YES NO Do you require any special equipment (braces, neck rolls, dental, orthotics, goggles, etc.) YES NO Have you ever had a Hernia? YES NO Have you ever had the chickenpox? If yes, when? YES NO Have you ever been diagnosed with a communicable disease (MRSA/Staph Infection, Sexually Transmitted Disease, HIV, Hepatitis, Herpes, Syphilis, Tuberculosis, meningitis, etc.)? If yes, when? _______________________________________ YES NO Are you aware of any reasons why you should not participate in intercollegiate athletics at UTD at this time? YES NO Have you had a tetanus booster within the past five (5) years? If yes, when? YES NO Have you ever received the Hepatitis B (HBV) Vaccination series (all 3 shots)? If yes, when? YES NO Do you use alcohol? If yes, how often? o 1 to 5 drinks/month; o 5 to 10/month; o more than 10 drinks/month YES NO Do you smoke cigarettes, use smokeless tobacco, or use tobacco in any form? YES NO Have you had a weight change (loss or gain) of greater than 10 pounds in the past year? YES NO Do you regularly lose weight to participate in your sport? YES NO Have you had a history of anorexia, bulimia (forced vomiting), and/or any other eating disorders? UTD ATHLETIC TRAINING 7 of 8
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Page 3 and 4: 2013-2014 IV. Allergies: Have You E
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Medical Health History Questionnaire - University of Texas at Dallas

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