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Microsoft word - athletic clearance medical history form.doc

LEBANON VALLEY COLLEGE
ATHLETIC CLEARANCE/MEDICAL HISTORY FORM
The information contained in this medical history form will only be used by the Sports Medicine Department of Lebanon
Valley College for purposes of determining if you pose a health threat / risk to yourself on the athletic field. This
information will remain CONFIDENTIAL at all times.

(Please print clearly in BLUE or BLACK INK ONLY!)

1. Allergies:
Have You Ever Been Diagnosed With Seasonal Allergies? Are You Presently Taking/Have You Previously Taken Any Allergy Medications? Are you allergic to and/or ever had an unfavorable / allergic reaction to any medications? Are you allergic to and/or ever had an unfavorable / allergic reaction to any food items? Are you allergic to and/or ever had an unfavorable / allergic reaction to bee stings, insect bites, etc.? 2. Asthma:
Have You Ever Been Diagnosed With Asthma and/or Exercised Induced Asthma? Are You Presently Taking / Have You Previously Taken Any Asthma Medications / Use an Inhaler? How Many Times Do You Use Your Rescue Inhaler (e.g. Albuterol, Proventil, etc.) During An Average Week? How Many Acute Asthma Attacks Have You Had In The Past 12 Months? Have You Ever Been Hospitalized As a Result of Asthma and/or Exercised Induced Asthma? Have You Ever Been Advised Not To Participate In Athletic Activities Due To Asthma Or Any Related Condition? 3. Cardiovascular Risk Factors:
Have you ever had chest pain and/or shortness of breath during or after exercise / practice? Have you ever felt dizzy, lightheaded, and/or passed out during or after exercise / practice? Have you ever had the feeling of your heart racing or skipping beats during or after exercise / practice? Do you get tired more quickly than your teammates / friends do during exercise / practice? Have you ever been told that you have a heart murmur? Has any family member or relative died of heart problems and/or of sudden death before age 50? Has a physician ever denied or restricted your participation in sports due to any heart / cardiovascular problems? Have you ever had an electrocardiogram (EKG) and/or echocardiogram (ECHO) of your heart? Does anyone in your family have a history of heart disease? Does anyone in your family have a history of Marfan Syndrome? Does anyone in your family have a history of high blood pressure? Have you ever been told that you have / had high blood pressure? Does anyone in your family have a history of high blood cholesterol? Have you even been told that you have / had high blood cholesterol? 4. Ear / Nose / Throat:
Have You Ever Suffered An Injury To Your Ear(s), Nose, and/or Throat? ♦ List Date(s) / Time Missed (e.g. practices or games) Have You Ever Been Hospitalized For A Ear, Nose, and/or Throat Injury? Have You Ever Been Advised Not To Participate In Athletic Activities Due To A Ear, Nose, and/or Throat Injury? Have You Ever Suffered An Injury To Your Eye(s) and/or Been Advised That You Have An Eye Disease? ♦ List Date(s) / Time Missed (e.g. practices or games) Have You Ever Been Hospitalized and/or Seen an Ophthalmologist for an Eye Injury? Have You Ever Been Advised Not To Participate In Athletic Activities Due To An Eye Injury? Do you routinely suffer from blurred vision, double vision, tunnel vision, and/or any other abnormal sight? Do you require any special devices / equipment? 6. Head Injuries / Concussion:
Have You Ever Suffered A Head Injury / Concussion (no matter how minor)? ♦ List Date(s) / Time Missed (e.g. practices or games) Have You Ever Been Evaluated By A Doctor For A Head Injury / Concussion? Have You Ever Been Hospitalized, Knocked Out, Become Unconscious, and/or Lost Your Memory Due To A Head Injury / Concussion? Have You Ever Been Advised Not To Participate In Athletic Activities Due To A Head Injury / Concussion? Do You Have A History of Migraine Headaches? Have You Had Headaches For More Than Three (3) Months? 7. Cervical Spine / Neck:
Have You Ever Suffered An Injury To Your Cervical Spine and/or Neck? ♦ List Date(s) / Time Missed (e.g. practices or games) Were Any Diagnostic Tests Performed? (If Yes check all that apply) Have You Ever Been Hospitalized For A Cervical Spine / Neck Injury? Have You Ever Had “Burners”, “Stingers”, or Brachial Plexus Injuries? Have You Ever Experienced Numbness and/or Tingling in Your Arms/Fingers? Have You Ever Had Surgery of Any Kind on Your Cervical Spine / Neck? Have You Ever Been Advised Not To Participate In Athletic Activities Due To A Cervical Spine / Neck Injury? Do You Presently Wear A Neck Roll / Collar, “Cowboy Collar” or Helmet Restrictor Plate? Have You Ever Worn or Been Advised To Wear a Neck Roll, Neck Collar, “Cowboy Collar”, and/or Helmet Restrictor Plate? 8. Spine / Low Back / Sacroiliac Joint:
Have You Ever Suffered An Injury To Your Spine / Low Back / Sacroiliac Joint? ♦ List Date(s) / Time Missed (e.g. practices or games) Were Any Diagnostic Tests Performed? (If Yes check all that apply) Have You Ever Been Hospitalized For A Spine / Low Back / Sacroiliac Joint Injury? Have You Ever Had Surgery of Any Kind on Your Spine / Low Back / Sacroiliac Joint? Have You Ever Had Numbness/Tingling Down One (1) or Both Legs? Have You Ever Been Advised Not To Participate In Athletic Activities Due To A Spine, Low Back, or SI Joint Injury? 9. Abdomen:
Have You Ever Been Diagnosed With A Problem With Your Stomach, Abdomen, Intestines, or Rectum? ♦ List Date(s) / Time Missed (e.g. practices or games) Have You Ever Suffered An Injury To Your Abdomen? ♦ List Date(s) / Time Missed (e.g. practices or games) Were Any Diagnostic Tests Performed? (If Yes check all that apply) Have You Ever Had Surgery For An Abdomen Injury? Do You Routinely Suffer From Severe Or Recurrent Abdominal Pain? Do you Routinely Suffer From Chronic or Recurrent Diarrhea? Do You Have Only One Of Two Paired, Functioning Organs (e.g. kidney, testicles, ovary, etc.)? Have You Ever Been Advised Not To Participate In Athletic Activities Due To An Abdomen Injury? 10. Shoulder / Upper Arm:
Have You Ever Suffered An Injury To Your Shoulder / Upper Arm? ♦ List Date(s) / Time Missed (e.g. practices or games) Were Any Diagnostic Tests Performed? (If Yes check all that apply) Have You Ever Been Hospitalized For A Shoulder / Upper Arm Injury? Have You Ever Had Surgery of Any Kind on Your Shoulder / Upper Arm? Have You Ever Been Advised Not To Participate In Athletic Activities Due To A Shoulder / Upper Arm Injury? 11. Ribs / Thorax / Chest:
Have You Ever Suffered An Injury To Your Rib / Thorax / Chest? ♦ List Date(s) / Time Missed (e.g. practices or games) Were Any Diagnostic Tests Performed? (If Yes check all that apply) Have You Ever Had Surgery For A Rib / Thorax / Chest Injury? Have You Ever Been Advised Not To Participate In Athletic Activities Due To A Ribs, Thorax, and/or Chest Injury? 12. Elbow / Forearm:
Have You Ever Suffered An Injury To Your Elbow / Forearm? ♦ List Date(s) / Time Missed (e.g. practices or games) Were Any Diagnostic Tests Performed? (If Yes check all that apply) Have You Ever Been Hospitalized For An Elbow / Forearm Injury? Have You Ever Had Surgery of Any Kind on Your Elbow / Forearm? Have You Ever Been Advised Not To Participate In Athletic Activities Due To A Elbow / Forearm Injury? 13. Wrist, Hand, & Fingers:
Have You Ever Suffered An Injury To Your Wrist(s), Hand(s), and/or Finger(s)? ♦ List Date(s) / Time Missed (e.g. practices or games) Were Any Diagnostic Tests Performed? (If Yes check all that apply) Have You Ever Been Hospitalized For A Wrist, Hand, and/or Finger Injury? Have You Ever Had Surgery of Any Kind on Your Wrist, Hand, and/or Finger(s)? Have You Ever Been Advised Not To Participate In Athletic Activities Due To A Wrist, Hand, and/or Finger Injury? 14. Thigh / Hamstring / Quadriceps:
Have You Ever Suffered An Injury To Your Thigh, Hamstring, and/or Quadriceps? ♦ List Date(s) / Time Missed (e.g. practices or games) Were Any Diagnostic Tests Performed? (If Yes check all that apply) Have You Ever Been Hospitalized For A Thigh, Hamstring, and/or Quadriceps Injury? Have You Ever Had Surgery For A Thigh, Hamstring, and/or Quadriceps Injury? Have You Ever Been Advised Not To Participate In Athletic Activities Due To A Thigh, Hamstring, or Quadriceps Injury? YES 15. Knee / Patella:
Have You Ever Suffered An Injury To Your Knee and/or Patella (kneecap)? ♦ List Date(s) / Time Missed (e.g. practices or games) Were Any Diagnostic Tests Performed? (If Yes check all that apply) Have You Ever Been Hospitalized For A Knee and/or Patella Injury? Have You Ever Had Surgery For A Knee and/or Patella Injury? Have You Ever Been Advised Not To Participate In Athletic Activities Due To A Knee / Patella Injury? Have You Ever/Do You Presently Wear A Knee Brace? 16. Hip / Groin:
Have You Ever Suffered An Injury To Your Hip / Groin (including hernias and/or sports hernias)? ♦ List Date(s) / Time Missed (e.g. practices or games) Were Any Diagnostic Tests Performed? (If Yes check all that apply) Have You Ever Had Surgery For A Hip / Groin Injury? Have You Ever Been Advised Not To Participate In Athletic Activities Due To A Hip and/or Groin Injury? 17. Ankle / Lower Leg:
Have You Ever Suffered An Injury To Your Ankle / Lower Leg? ♦ List Date(s) / Time Missed (e.g. practices or games) Were Any Diagnostic Tests Performed? (If Yes check all that apply) Have You Ever Been Hospitalized For An Ankle / Lower Leg Injury? Have You Ever Had Surgery For An Ankle / Lower Leg Injury? Have You Ever Been Advised Not To Participate In Athletic Activities Due To An Ankle / Lower Leg Injury? 18. Foot / Toes:
Have You Ever Suffered An Injury To Your Foot / Toe(s)? ♦ List Date(s) / Time Missed (e.g. practices or games) Were Any Diagnostic Tests Performed? (If Yes check all that apply) Have You Ever Had Surgery For A Foot / Toe Injury? Have You Ever Been Advised Not To Participate In Athletic Activities Due To An Foot and/or Toe Injury? 19. Dental:
Have You Ever Suffered An Injury To Your Mouth, Jaw, and/or Teeth? ♦ List Date(s) / Time Missed (e.g. practices or games) Have You Ever Been Hospitalized For A Mouth, Jaw, and/or Tooth Injury? Do you have Bridge/False Teeth/Caps/Plates/Crowns? 20. Medical Testing:
Have You Ever Been Diagnosed With a Communicable Disease (e.g. STD, HIV, Hepatitis A, B, or C, Herpes Simplex, Syphilis, Tuberculosis)? 21. Dermatological:
Do you have any skin problems that we should be aware of (e.g. itching, rashes, acne, warts, eczema, fungus, etc.)? Have you ever been under the care of a dermatologist for any condition? Have you ever been advised not to participate in athletic activities due to a skin condition? 22. Sickle Cell Anemia:
Have you ever been tested for Sickle Cell Anemia that you are aware of? Does any member of your family carry the Sickle Cell Trait / have Sickle Cell Anemia that you are aware of? Have you ever been advised that you carry the Sickle Cell Trait / have Sickle Cell Anemia? 23. Diabetic History:
Have You Ever Been Diagnosed With Diabetes? Are You Presently Taking or Have You Taken Any Diabetic Medications? Medication
Frequency
Do You Daily Monitor Your Blood Sugar Level? Have You Had Your A1C Level Checked Within The Last Three (3) Months? Have You Had Any Hypoglycemic Episodes (low blood sugar) Within The Last Twelve (12) Months? Have You Ever Been Advised Not To Participate In Athletic Activities Due To Diabetes? Please List Any Precautions That You Take and/or Additional Information Not Mentioned Above: 24. Heat Related Problems:
Have You Ever Suffered From A Heat Related Injury? Have You Ever Received Intravenous Fluids (IV) For A Heat Related Problem? Have You Ever Been Hospitalized For a Heat-Related Problem? Have You Ever Been Advised Not To Participate In Athletic Activities Due To A Heat Related Injury? 25. Prescription Medications:
Please List ALL Prescription & Over-the-Counter Medications That You Are CURRENTLY Taking or Have Taken
In The PAST Two (2) Years, & For What Purpose:
MEDICATION PURPOSE DOSAGE
26. Supplements / Ergogenic Aids:
Please List ALL Supplements / Ergogenic Aids That You Are CURRENTLY Taking or Have Taken In The PAST Two (2)
Years, & For What Purpose:
SUPPLEMENT PURPOSE DOSAGE
27. Please Answer: {All questions are strictly CONFIDENTIAL & will not be shared with parents or coaches!}
Have you ever had any injury or illness other than those already noted? Do you have any ongoing or chronic illnesses? Have you ever been hospitalized overnight? Have you ever been told by a physician to restrict your sports activity or not to participate in a sport? Are you currently under a physician’s care for any medical conditions? Have you ever been under the care of a psychiatrist and/or psychologist? Have you consulted and/or been under the care of a chiropractor, hypnotist, acupuncturist, massage therapist, practitioner in the past five (5) years? Have you ever had a rash or hives develop during and/or after exercise? Do you cough, wheeze, or have trouble breathing during or after exercise / practice? Have you ever been told that you have kidney disease? Have you ever had rubella (“German Measles”) and/or Rubeola (“red measles”)? Have you ever had a stomach and/or duodenal ulcer? Have you had a viral infection (i.e. mononucleosis, myocarditis, etc.) within the past six (6) months? Have you ever had seizures, convulsions, and/or epilepsy? Have you ever had gall bladder disease and/or a urinary problem? Do you have ringing in your ears or trouble hearing? Do you have frequent ear infections or nosebleeds? Have you ever had an abnormal chest x-ray and/or pneumonia? Do you require any special equipment (braces, neck rolls, dental, orthotics, hearing aids, etc.) Have you ever had the chickenpox? If yes, when? Are you aware of any reasons why you should not participate in intercollegiate athletics at Lebanon Valley College at Have you had a tetanus booster within the past five (5) years? If yes, when? Have you ever received the Hepatitis B (HBV) Vaccination series (all 3 shots)? If yes, when? Do you smoke cigarettes, use smokeless tobacco, or use tobacco in any form? Have you ever used / tried marijuana, cocaine, or any other illicit “street” drugs? Do you have any questions regarding drugs, tobacco, or alcohol? Do you feel stressed out? If yes, do you feel as though you get the necessary support to deal with your stress? Have you had a weight change (loss or gain) of greater than 10 pounds in the past year? Are you a vegetarian? If yes, what type? Do you regularly lose weight to participate in your sport? Do you want to weigh more or less than you presently do? Have you ever felt forced to limit your food intake due to concerns about your weight and/or body size? Have you had a history of anorexia, bulimia (forced vomiting), and/or any other eating disorders? Would you like to meet with a dietitian to discuss your nutritional needs or eating habits?
If you have answered YES to any of the above, please explain:
Please describe below any further injury information, which is knowledgeable to you and not required
on this form.

I, the undersigned, hereby acknowledge, affirm, and represent that all statements on pages one (1) through fourteen (12) are true and accurate to the best of my knowledge; and that no answers or information have been withheld. If any information and/or statements are false and/or have been omitted in reference to my past and/or present medical history, I understand and acknowledge that my health and physical welfare may be jeopardized as a result and that I may suffer physical harm. Parent/Guardian Signature (if under 18 years of age) Reviewed By Lebanon Valley College Staff ATC:

Source: http://www.lvc.edu/health-services/MedHistfrm-athetics.pdf

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