Sports medical evaluation (pdf) - Bethel University

Do you get tired more quickly than your friends do during exercise?-Explanation of Above:INFECTIOUSHave you recently had a Tuberculosis Skin Test? If yes; results were: NegativeHave you had infectious mononucleosis (mono) within the last month?Have you had chicken pox?Have you had measles?Have you had mumps?-Explanation of Above:SKINDo you have any rashes, pressure sores, or other skin problems?Have you had a herpes skin infection?-Explanation of Above:PositiveYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoNEUROLOGICHave you ever had a head injury, concussion, been knocked out, or had your “bell rung”?Have you been hit in the head and been confused or lost your memory?Have you ever had a seizure?Do you have headaches with exercise?Have you ever had a “stinger or burner”Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?Have you ever been unable to move your arms or legs after being hit or falling?-Explanation of Above:BLOODHave you ever been told you are anemic?Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease?Have you been tested for sickle cell trait?Any other blood disorder?-Explanation of Above:VISIONHave you had any problems with your eyes or vision?Do you wear glasses or contact lenses?Do you wear protective eyewear, such as goggles or a face shield?-Explanation of Above:NUTRITIONAre you taking any supplements?Are you happy with your weight?Are you trying to gain or lose weight?What has been your highest & lowest weight in the past 12 months? _________________________Has anyone recommended you change your weight or eating habits?Do you limit or carefully control what you eat?Have you ever been diagnosed with an eating disorder?-Explanation of Above:FEMALES ONLYHave you ever had a menstrual period?How old were you when you had your first menstrual period? _______________How many menstrual periods have you had in the last year? ________________-Explanation of Above:MALES ONLYHave you ever had an injury to a testicle or other reproductive organs?Do you or have you had undescended testicles?-Explanation of Above:ENTHave you had multiple ear infections?Do you have loss of hearing in one or both ears?-Explanation of Above:ABDOMINALHave you ever had an ulcer?Do you have a history of gastrointestinal (GI) problems?Do you experience abdominal pain multiple times per month?Have you had your appendix removed?-Explanation of Above:UROLOGYHave you had multiple urinary tract /bladder infections?Have you ever had a kidney infection?Have you ever had kidney or gall stones?-Explanation of Above:Yes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/No