LUTHER COLLEGE VARSITY ATHLETIC HEALTH-STATUS QUESTIONNAIRE Participation History To be completed by the Student Athlete
Students participating in intercollegiate athletics must have a complete physical examination including orthopedic screening. A student-athlete who has
sustained a significant injury or illness within the past 12 months must receive clearance from a physician before resuming participation in a varsity sport.
Name __________________________________________________________ Date of Birth _____/______/______ Year in College: 1 2 3 4
ID Number _____________________________Sport _____________________________________________________________________________
Phone Number: (______) ________ - ____________ Luther Email: __________________________________________________________
Tetanus (must be within 10 years) _________________________ Are you CURRENTLY under the care of a physician for any chronic medical condition? Yes No If yes, please indicate condition and treatment. ____________________________________________________________ Have you ever: date date Passed out during exercise? .. Yes No _____________ Had seizure/convulsions? Yes No __________ Had chest pain during exercise? Yes No _____________ Been dizzy during exercise? . Yes No __________ Had a heart attack? . Yes No _____________ Had a head injury/concussion? Yes No __________ Been told you have a heart murmur? Yes No _____________ Been knocked out? .. Yes No __________ Had racing heart/skipping beats? Yes No _____________ Had asthma or wheezing? ... Yes No __________ Had heat exhaustion/heat stroke? Yes No _____________ Use an inhaler before you exercise?........ Yes No __________ Been dizzy or passed out due to heat? Yes No _____________ Have you been hospitalized or had a surgical operation? Yes No If yes, explain: __________________________________________________________ ______________________________________________________________________________________________________________________________________ Has anyone in your family died from heart problems or died suddenly before age 55? Yes No If yes, explain:_____________________________________ _______________________________________________________________________________________________________________________________________
Do you: Have weakness, pain, or swelling in any of the following? Have high blood pressure? yes no Y N Y N Y N Y N Tire more quickly than your friends during exercise? yes no Hand. Arm. Back.. Shin/Calf Smoke cigarettes? (number per day: ____) .. yes no Wrist. Shoulder Hip.. Ankle. Use smokeless tobacco? .. yes no Forearm Neck. Thigh Foot Have more than 2 alcoholic drinks per week? .. yes no Elbow Chest Knee.. Back.... Have very irregular or absent periods? .. yes no Have diabetes? . yes no Must you use special equipment for completion (pads, braces, neck roll, etc.)? Wear eyeglasses/contact lenses/ protective eyewear? yes no Yes No Are you missing one of any paired organ? (eye, kidney testicle) Yes No If yes, please explain: _________________________________________________ Have you had mononucleosis recently? Yes No If yes, provide date: _____________________________________________________________________ Have you ever or are you currently being treated for any eating disorder? Yes No If Yes, explain:_______________________________________________ Are you now receiving or have you ever received treatment or counseling for mental health illness or substance abuse? Yes No If yes, please explain: ________________________________________________________________________________________________________________ Sickle cell status: positive negative unknown/waived
If Unknown/waived: I have completed the 2nd Education sessions. Yes No
Are you presently taking any medications (birth control, prescriptions meds, vitamins, aspirin, etc.): ________________________________________________________________________________________________________________________ Have you or are you currently taking performance enhancement supplements (creatine, etc): ________________________________________________________________________________________________________________________ Please list any allergies you may have (medicine, bees, food, etc): ________________________________________________________________________________________________________________________ I, the undersigned herewith declare to the best of my knowledge, that the above questions have been answered truthfully and correctly and
A. Understand that I must refrain from practice or play during medical treatment until I am discharged from treatment or given a written permit by the attending physician to resume participation.
B. Understand that having completed the pre-participation screening process does not necessarily mean I am physically qualified to engage in athletics, but only that the examiner did not find a medical reason to disqualify me.
C. Understand that I cannot participate (practice or compete) until this form is signed by a Physician/Physician Assistant D.
Student Athletes Signature ________________________________________________________________________ Date __________________________________
PRE-PARTICIPATION MEDICAL SCREEN TO BE COMPLETED BY PHYSICIAN/PHYSICIAN ASSISTANT
PHYSICAL EXAMINATION Height without Shoes _________________ Weight _____________________ Blood Pressure _____________Pulse_____________ Vision: Corrected lenses Uncorrected Left eye: ___________________ Right eye: _______________________ I have reviewed the medical history with this student-athlete Yes No Is there any medical history or an injury or illness within the past 12 months which might limit full participation in a varsity sport? Yes No If yes, state reason________________________________________________________________________________________________________
TO BE COMPLETED BY PHYSICIAN Normal Abnormal Describe findings, please refer to item number
1. Head .. ________________________________________________________ 2. Eyes (pupils), ENT. ________________________________________________________ 3. Teeth ________________________________________________________ 4. Chest . ________________________________________________________ 5. Lungs . ________________________________________________________ 6. Heart . ________________________________________________________ 7. Abdomen. ________________________________________________________ 8. Neurologic . ________________________________________________________ 9. Skin ... ________________________________________________________ 10. Physical Maturity .. ________________________________________________________
ASSESSMENT Full Sport Participation/Cleared Limited Participation (describe limitations, restrictions) ___________________________________ ________________________________________________________________________________ ________________________________________________________________________________ No Clearance (list reasons) _____________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Recommendations ______________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
Physicians Signature ______________________________________________________Date _____________________ Physicians Name (printed) ___________________________________________________________________________