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Concordia College First Year Preparticipation Health History
Please print form, fill out completely and return to:
Stephanie Brandt - Athletic Trainer
Concordia College
901 South 8th Street
Moorhead, MN 56562

Background

1. Name
2. Date of Birth
//
month / day / year

3. GenderMaleFemale

4. Academic Class (for the upcoming year)

 
Freshman Sophomore Junior Senior
5. Varsity sport(s) (Mark with an "x" all that apply, enter a # for years played)
 
Plan to play # of years played Plan to play # of years played
this year at college level this year at college level
Baseball Softball
Basketball Swimming
Cross Country Tennis
Football Track and Field
Golf Volleyball
Ice Hockey Wrestling
Soccer

 
Medical History 

7. How many years has it been since your last complete health examination, other than an exam that was required for you to participate in sports?

1 Year2 Years3 Years>3 Years
Never had a complete health exam other than for sports
8. Are you presently taking any prescribed or over the counter medication? (including birth control pills, insulin, allergy shots or pills, asthma inhalers, vitamin or mineral supplements including iron, anti-inflammatories including aspirin)
Yes (if so, please fill out the table below)
Name of Medication Dose Frequency of Use

No

9. Do you have an allergy to any:
 
Yes No Specify Allergy:
drug or medicine (over the counter or prescribed)
foods
insects or animals
plants, grasses, pollen, dust or other environmental factors
other
10. Has a doctor ever told you that you have had any of the following medical problems?
(if you don't know, mark 'No')
 
Yes No Yes No
mononucleosis injury to liver or spleen
rubella (German measles) hepatitis
chicken pox jaundice
repeated sinus infections stomach or intestinal ulcer
nose fracture hernia
hearing defect or loss diabetes
recurrent ear infection sickle cell anemia/carrier
epilepsy other anemia
tumor, growth, cyst, cancer abnormal bleeding or clotting disorder
over-active thyroid blood clot or embolism
under-active thyroid leukemia or other blood disorder
arthritis kidney injury
Marfan syndrome other kidney disease
oral herpes (cold sores) frequent urinary infections
11. Have you ever had surgery to the following:
 
Yes No Date
(month/year)		 If yes, give reason for surgery:
eyes /
ears/nose/throat /
heart /
lungs /
stomach or bowels/appendix /
kidneys /
liver/spleen /
bone /
muscle/ligament/tendon /
joint /
other (please specify)
/
12. Were you born with two normal:
 
Yes No If no, specify abnormality:
eyes
ears
kidneys
13. Do you presently have the following skin problems:
 
Yes No
rash
fungal infection
cold sore(s)
14. Have you ever had heat exhaustion/heat stroke/sun stroke?
YesNo

15. During or after exercise, have you ever:

 
Yes No
been dizzy or light- headed?
passed out (fainted)?
had chest pain, discomfort or tightness?
found it more difficult to breath than usual?
had problems with coughing?

16. Have you ever been told that you have a heart murmur?YesNo

17. Have you ever had racing of your heart, irregular or skipped beats?YesNo

18. Have you ever been told by a doctor that you have had:

 
Yes No
high blood pressure?
pericarditis, myocarditis, endocarditis (infections of the heart)?
rheumatic fever?
other heart or vascular problems? (please specify)
19. Have you ever had any medical tests for your heart (i.e. EKG, echocardiogram)?
Yes (if so, specify test and reason below)
Test Reason

No

20. Have you ever had:
 
Yes No
bronchitis?
tuberculosis?
asthma?
wheezing that starts during or just after exercise?
pneumothorax (collapsed lung)?
21. Have you ever had a concussion (injury to the head) with or without loss of consciousness?
Yes (if so, please complete the table below)
How many times?1x2x3x4x5x>5x

No

22. Have you ever been knocked unconscious?
Yes (if so, please complete the table below)
How many times?1x2x3x4x5x>5x
What is the longest time that you have been unconscious due to a head injury?
A few secondsUp to 5 minutes6-15 minutes>15 minutes

No

23. Have you ever had any long term problems due to a head injury (e.g. memory loss, headaches)?
YesNo

24. Have you ever had numbness, tingling, or weakness in your:

 
Yes No
shoulders/arms/hands?
buttocks?
legs/feet?
25. Have you ever had a "burner" or "stinger" (an injury causing a sudden burning pain and numbness down the arm and/or hand)?YesNo

26. Have you ever had a seizure?YesNo

27. Do you experience migraine headaches?YesNo

28. Have you ever had a serious eye injury?

Yes (if so, please specify below)

No

29. Do you wear glasses or contact lenses?
Yes (if so, please complete the table below)
Do you wear glasses or contacts when you train or compete?  YesNo
Have you had your eyes checked in the past 12 months?  YesNo

No

30. Are you legally blind in either of your eyes?YesNo
WOMEN ONLY, MEN SKIP TO QUESTION #36

31. At what age did your menstrual periods start?years of age

32. When was your most recent menstrual period?

 
<1 month ago 1-3 months ago 4-6 months ago >6 months ago

33. In the past 12 months:

 
Yes No
have you had trouble with heavy menstrual bleeding?
have you had bleeding between periods?
have you had menstrual cramps or pain which affected your school or athletic performance?
have you had any unusual discharge from your vagina?
how many periods have you had?01-34-67-12>12
what was the longest time between periods?<1 month1-3mo4-6mo>6mo
on average how long has each period lasted?1-5 days6-10d11-15d>15d
34. Are you presently taking any female hormones (estrogen, progesterone, birth control pills) for the purpose of regulating your periods?YesNo

35. Have you ever had a pelvic exam / Pap smear?

Yes (if so, please complete the table below)
When was your last pelvic exam/PAP smear?<1 yr1-3 yrs>3 yrs
Has your pelvic exam / Pap smear ever been abnormal?YesNo

No
MEN ONLY, WOMEN SKIP TO QUESTION # 38

36. Were you born with two normal testes?YesNo

37. Have you ever had surgery to remove or repair a testicle(s)?YesNo

Orthopaedic History 

38. In the past 12 months have you seen a physician, athletic trainer or other health care professional for a new or ongoing injury?

Yes (if so, please complete the table below)
Specify injury(s): Has this injury healed completely?
YesNo
YesNo
YesNo
YesNo
YesNo

No

39. Do you presently use for practice or competition:
 
Yes No
a brace, splint, or sleeve?
orthotics (shoe inserts)?

























  QUESTIONS 40-51

Have you ever had or do you currently have an injury or problem of the following:
(if you don't know, leave 'No' box marked)

 
    Yes No Place an "x" if condition exists at present     Yes No Place an "x" if condition exists at present
40. Neck:
disc disease
  facet disorder
traumatic fracture
  surgery
stress fracture
  other
whiplash
  ® specify:
 
41. Spine / Back:
cogenital deformity or   disc disease
    birth defect
  facet disorder
traumatic fracture
  sacroiliac disorder
stress fracture
  sciatica
back pain
  scoliosis
back stiffness
  surgery
spondyloysis
  other
spondylolisthesis
  ® specify:
 
42. Shoulder / Clavicle:
traumatic fracture
  subluxation
bursitis
  dislocation
acromioclavicular (AC) separation
  surgery
rotator cuff tendonitis/ impingement
  other
instability
  ® specify:
 
    Yes No Place an "x" if condition exists at present     Yes No Place an "x" if condition exists at present
43. Upper arm / forearm:
traumatic fracture
  surgery
muscle injury
  other
tendon injury
  ® specify:
 
44. Elbow:
traumatic fracture
  dislocation
ligament injury
  surgery
tennis (golfer's) elbow
  other
bursitis
  ® specify:
 
45. Hand, Wrist, Fingers:
traumatic fracture
  dislocation
stress fracture
  surgery
ligament injury
  other
tendon injury or tendonitis
  ® specify:
 
    Yes No Place an "x" if condition exists at present     Yes No Place an "x" if condition exists at present
46. Pelvis / Hip:
traumatic fracture
  tendonitis
stress fracture
  contusion/hip pointers
groin strain
  surgery
dislocation
  other
bursitis
  ® specify:
 
47. Thigh:
traumatic fracture
  quadriceps strain/injury
stress fracture
  severe contusion
tendonitis
  surgery
bursitis
  other
hamstring strain/injury
  ® specify:
 
48. Knee:
meniscal injury
  locking
PCL tear
  dislocation of knee or
ACL tear
     patella (knee cap)
iliotibial band syndrome
  swelling
collateral ligament injury
  unexplained pain
tendonitis
  meniscal surgery
bursitis
  ACL surgery
pain around knee cap, (patello-femoral pain)
  other injury or surgery
sensation of catching, instability, giving away
  ® specify:
 
    Yes No Place an "x" if condition exists at present     Yes No Place an "x" if condition exists at present
49. Lower Leg:
traumatic fracture
  shin splints
stress fracture
  surgery
muscle strain
  other
compartment syndrome
  ® specify:
 
50. Ankle:
traumatic fracture
  bone chip in joint
stress fracture
  dislocation
sprain
  surgery
tendonitis
  other
bursitis
  ® specify:
instability
 
 
51. Foot / Toes:
traumatic fracture
  flat arches of feet
stress fracture
  dislocation
sprain
  surgery
tendonitis or tendon injury
  other
bone spur
  ® specify:
plantar fasciitis
 

52. In the past 10 years, have you been treated for a serious injury(s) not mentioned above?

Yes (if so, please specify below)
Specify injury(s): Date (month/year):
/ 
/ 
/ 

No

53. In the past 12 months, what is the total number of days of training and competition that you have been unable to participate in due to any injury?
(Pick the most appropriate category for each injury you have had. List each injury only once)
 
never had 1-7 days 8-14 days >14 days Specify injury site or type
shin splints
traumatic fracture(s)
stress fracture(s)
tendonitis or tendon injury(s)
bursitis
sprain
pulled muscle(s)
back problem(s)
ligament injury or tear
joint injury(s) or pain
other injury
other injury
other injury
54. Have you ever had a cortisone injection into a tendon, bursa, or joint for an injury or pain?
Yes (if so, please specify below)
Specify injury(s): Date (month/year):
/ 
/ 

No
Family History 

55. For each full-blood relative listed, please indicate if they have a history of the following (do not include adoptive, step, or foster relatives) (Place an 'x' in all boxes that apply; mark 'No history in family' if appropriate or if family history unknown):

 
No history in family Mother/Father Brother/Sister Grandparent
high blood pressure
heart attack
other heart abnormalities
high blood cholesterol
diabetes
arthritis
bleeding disorder
Marfan syndrome
kidney disease
mental illness
sickle cell anemia
epilepsy
cancer
56. Have any of your full-blood relatives (father/mother, brother/sister, grandparent) died suddenly before the age of fifty, other than due to trauma?
Yes (if known, please specify reason below)

No

57. Please indicate your ethnic origin (place an 'x' in all that apply)
 
Native American / Alaska native Hispanic/Latino/Chicano
Asian White (non-Hispanic)
Pacific Islander Other, specify:
Black/African American Don't know

 
The above statements are true to the best of my knowledge.  This athlete gives consent for the team physician, consulting physician,
Concordia Student Health Personnel and/or appropriate member of the sports medicine staff of Concordia College to examine records, or be in consultation concerning examination or treatment of the athlete for the express prupose of evaluating the medical and/or physical fitness for participation in, or continued participation in any athletic program at Concordia College.  The athlete/parent also gives permission for acceptable diagnostic, therapeutic and emergency operative procedures to be carried out in the treatment of illness and injury sustained while a member of a Concordia College Athletic Teams.
Signed                       Date