PRE-PARTICIPATION MEDICAL EVALUATION

(MEDICAL HISTORY)
(Note: This form is to be filled out by the student along with his parent/guardian prior to seeing the physician. The physician should
keep this form in the chart. By signing this form, the student/parent/guardian consents to disclosure of the information provided..)

Name of Student ______________________________________________ Date of Exam _____________________________

Sex _____ Age _____ Purpose Fit to Travel for Student Internship Abroad

Medicines and Allergies:

Please list all of the prescription and over-the-counter medicines and supplements that you are currently taking
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Do you have any allergies? [ ] Yes [ ] No If yes, please identify specific allergy below.
[ ] Medicines __________________ [ ] Food ______________________ [ ] Others ________________________________________

For all Yes answers, elaborate Why, When, and Duration of the illness/symptoms. If the line provided below is not sufficient, please use dorsal
side or separate paper. Encircle the questions you do not know the answers to.

GENERAL QUESTIONS YES NO

1. Has a doctor ever denied or restricted your participation in sports for any reason? ____ ___
2. Do you have any ongoing medical conditions? ____ ___
If so, please identify: [ ] Asthma [ ] Anemia [ ] Diabetes [ ] Hypertension [ ] Seizure [ ] Heart Ailment [ ] Other ___________
3. Have you ever spent the night in the hospital? ____ ___
4. Have you ever had surgery? ____ ___
HEART HEALTH QUESTIONS ABOUT YOU
5. Have you ever passed out or nearly passed out DURING or AFTER exercise? ____ ___
6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? ____ ___
7. Does your heart ever race (or skip beats) during exercise? ____ ___
8. Has a doctor ever told you that you have heart problems? ____ ___
If so, check all that apply: [ ] High Blood Pressure [ ] High Cholesterol [ ] Heart Murmur
[ ] Heart Infection [ ] Heart Disease [ ] Other ____________________
9. Has a doctor ever ordered a test for your heart as ECG, Echocardography,etc? ____ ___
10. Do you feel lightheaded or feel more short of breath than expected during exercise? ____ ___
11. Do you get more tired or short of breath more quickly than your friends during exercise? ____ ___
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
13. Has any family member died of heart problem or had an unexpected or unexplained death before the age
of 45? ____ ___
14. Has anyone in your family have a heart problem, pacemaker or implanted defibrillator? ____ ___
15. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? ____ ___
BONE AND JOINT QUESTION
16. Have you ever had an injury to your bone, ligament, muscle or tendon that caused you to miss a game
or a practice? ____ ___
17. Have you ever had a broken or fractured bones or dislocated joints? ____ ___
18. Have you ever had an injury that required x-rays, MRI, CT Scan, injections, therapy, cast, brace, or crutches? ____ ___
19. Do you have a joint, muscle, or bone injury that bothers you? ____ ___
20. Do any of your joints become painful, swollen, feel warm or look red? ____ ___
MEDICAL QUESTIONS
21. Do you cough, wheeze or have difficulty of breathing during or after exercise? ____ ___
22. Have you ever used an inhaler or taken asthma medicine? ____ ___
23. Is there anyone in your family who has asthma? ____ ___
24. Do you have a groin pain or a painful bulge or hernia in your groin area? ____ ___
25. Do you have any rashes, pressure sores or any skin problems? ____ ___
26. Have you ever had a head injury or concussion? ____ ___
27. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problem? ____ ___
28. Do you have a history of seizure disorder? ____ ___
29. Do you have headaches with exercise? ____ ___
30. Have you ever had numbness, tingling or weakness in your arms or legs after being hit or falling? ____ ___
31. Have you ever become ill after exercising in the heat? ____ ___
32. Have you had any problems with your eyes or vision? ____ ___

Explain YES answers here (if insufficient space, please use dorsal or a separate piece of paper)
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I declare, under the penalties of perjury, that this form has been completed in good faith, verified by me, and to the best of my
knowledge and belief, is true and correct.

Printed Name and Signature of Student ____________________________________________________________________

Printed Name and Signature of Parent/Guardian_____________________________________________________________

Relation to Student _____________________________________________________________________________________
Date________________________________________________________