History evaluation form

SPORTS HEART SCREENING
Name: ______________________________________ Sex: ______ Age: ________________
Date of Birth: ____-____-______ Grade: ____________ School: _______________________
Sport(s):____________________________________________________________________
Address/City/State/Zip:________________________________________________________
Phone:_________________________ Location of Screening:___________________________
Personal Physician:____________________________________________________________
Parent/Guardian Name:________________________________________________________

Relationship:_______________________________ Phone:____________________________

CIRCLE QUESTIONS YOU DON’T KNOW THE ANSWERS TO.
EXPLAIN “YES” ANSWERS AFTER QUESTION.
1. HAVE YOU EVER PASSED OUT DURING OR AFTER EXERCISE? 2. HAVE YOU EVER BEEN DIZZY DURING OR AFTER EXERCISE? 3. HAVE YOU EVER HAD CHEST PAIN DURING OR AFTER EXERCISE? 4. DO YOU GET TIRED MORE QUICKLY THAN YOUR FRIENDS DO DURING EXERCISE? 5. HAVE YOU EVER HAD RACING OF YOUR HEART OR SKIPPED HEARTBEATS? 6. HAVE YOU HAD HIGH BLOOD PRESSURE OR HIGH CHOLESTEROL? 7. HAVE YOU EVER BEEN TOLD YOU HAVE A HEART MURMUR? 8. HAS ANY FAMILY MEMBER OR RELATIVE DIED OF HEART PROBLEMS OR OF SUDDEN CARDIAC DEATH 9. HAVE YOU HAD A SEVERE VIRAL INFECTION (FOR EXAMPLE, MYOCARDITIS OR MONONUCLEOSIS) 10. HAVE YOU BEEN PREVIOUSLY DIAGNOSED WITH HEART PROBLEMS? 11. DO YOU HAVE A FAMILY HISTORY OF HEART DISEASE? 12. DO YOU COUGH, WHEEZE OR HAVE TROUBLE BREATHING DURING OR AFTER ACTIVITY? 13. DO YOU HAVE ASTHMA? 14. DO YOU HAVE SEASONAL ALLERGIES THAT REQUIRE MEDICAL TREATMENT? 15. HAVE YOU HAD A MEDICAL ILLNESS OR INJURY SINCE YOUR LAST CHECKUP OR SPORTS PHYSICAL? 16. ARE YOU CURRENTLY TAKING ANY PRESCRIPTION OR NONPRESCRIPTION (OVER-THE-COUNTER) MEDICATIONS OR PILLS OR USING AN INHALER? 17. DO YOU HAVE ALLERGIES (FOR EXAMPLE, TO POLLEN, MEDICINE, FOOD OR STINGING INSECTS)?
18. DO YOU USE TOBACCO PRODUCTS?
19. DO YOU CONSUME ALCOHOLIC BEVERAGES?
20. DO YOU CONSUME CAFFEINE DAILY?
21. DO YOU HAVE AN EATING DISORDER (FOR EXAMPLE, ANOREXIA OR BULIMIA)?
22. HAVE YOU HAD PERSISTENT HEADACHES, VISUAL CHANGES, OR FREQUENT DIZZINESS?
23. DO YOU USE MUSCLE ENHANCING SUBSTANCES?
24. HAVE YOU BEEN DIAGNOSED WITH MARFAN’S SYNDROME?
SIGNATURE OF PARENT/GUARDIAN/STUDENT(IF OVER 18):
_______________________________________________________________ DATE: _______________________
Transmed, Inc.
ATHLETIC HEART SCREENING
P:(605) 941-2939 F: (605) 274-0620
Name: _______________________________________________ Sex: ______ Age: ______
Date of Birth: ____-____-______ Grade: ____________ School: _______________________
Sport(s):____________________________________________________________________
Address/City/State/Zip:________________________________________________________
Phone:_________________________ Location of Screening:___________________________
Personal Physician:____________________________________________________________
Parent/Guardian Name:________________________________________________________

Relationship:_______________________________ Phone:____________________________

CIRCLE QUESTIONS YOU DON’T KNOW THE ANSWERS TO.
EXPLAIN “YES” ANSWERS AFTER QUESTION.
1. HAVE YOU EVER PASSED OUT DURING OR AFTER EXERCISE? 2. HAVE YOU EVER BEEN DIZZY DURING OR AFTER EXERCISE? 3. HAVE YOU EVER HAD CHEST PAIN DURING OR AFTER EXERCISE? 4. DO YOU GET TIRED MORE QUICKLY THAN YOUR FRIENDS DO DURING EXERCISE? 5. HAVE YOU EVER HAD RACING OF YOUR HEART OR SKIPPED HEARTBEATS? 6. HAVE YOU HAD HIGH BLOOD PRESSURE OR HIGH CHOLESTEROL? 7. HAVE YOU EVER BEEN TOLD YOU HAVE A HEART MURMUR? 8. HAS ANY FAMILY MEMBER OR RELATIVE DIED OF HEART PROBLEMS OR OF SUDDEN CARDIAC DEATH 9. HAVE YOU HAD A SEVERE VIRAL INFECTION (FOR EXAMPLE, MYOCARDITIS OR MONONUCLEOSIS) 10. HAVE YOU BEEN PREVIOUSLY DIAGNOSED WITH HEART PROBLEMS? 11. DO YOU HAVE A FAMILY HISTORY OF HEART DISEASE? 12. DO YOU COUGH, WHEEZE OR HAVE TROUBLE BREATHING DURING OR AFTER ACTIVITY? 13. DO YOU HAVE ASTHMA? 14. DO YOU HAVE SEASONAL ALLERGIES THAT REQUIRE MEDICAL TREATMENT? 15. HAVE YOU HAD A MEDICAL ILLNESS OR INJURY SINCE YOUR LAST CHECKUP OR SPORTS PHYSICAL? 16. ARE YOU CURRENTLY TAKING ANY PRESCRIPTION OR NONPRESCRIPTION (OVER-THE-COUNTER) MEDICATIONS OR PILLS OR USING AN INHALER? 17. DO YOU HAVE ALLERGIES (FOR EXAMPLE, TO POLLEN, MEDICINE, FOOD OR STINGING INSECTS)? 18. DO YOU USE TOBACCO PRODUCTS? 19. DO YOU CONSUME ALCOHOLIC BEVERAGES? 20. DO YOU CONSUME CAFFEINE DAILY? 21. DO YOU HAVE AN EATING DISORDER (FOR EXAMPLE, ANOREXIA OR BULIMIA)? 22. HAVE YOU HAD PERSISTENT HEADACHES, VISUAL CHANGES, OR FREQUENT DIZZINESS? 23. DO YOU USE MUSCLE ENHANCING SUBSTANCES? 24. HAVE YOU BEEN DIAGNOSED WITH MARFAN’S SYNDROME?
SIGNATURE OF PARENT/GUARDIAN/STUDENT(IF OVER 18):
.
_______________________________________________________________ DATE: _______________________

Source: http://meade.k12.sd.us/sbhs/History%20Evaluation%20Form.pdf