Eureka College New Student Packet 2013-14 | Page 21

Physical Evaluation

Name ___________________________________________________ Male
Female Age _____
Date of Birth ____ / ____ / ____
Parent/Guardian _____________________________ Home Phone _____________________________
Home Address ________________________________________________________________________
Sport(s) ____________________________________________________________________________
In case of emergency, contact _______________________ Relationship _________________________
Phone(s) ___________________________________________________________________________
Yes
NO
Please explain any YES answers at the bottom of the page.
Have you had a medical illness or injury since your last check-up or sports physical?--------------------------Have you been/ are currently being treated by a health care professional during the last five years?----------Do you have a chronic or ongoing illness that includes cancer, tuberculosis, diabetes, hepatitis?-------------Do you have a chronic or persistent cough?----------------------------------------------------------------------------Have you ever had surgery?-----------------------------------------------------------------------------------------------Are you presently taking any prescription or non-prescription drugs including an inhaler?-------------------Do you have any allergies? (Insect stings, foods, medicines)--------------------------------------------------------Have you ever had a rash or hives develop after exercise? ad rheumatic fever?-----------------------------------Have you ever passed out during exercise?-----------------------------------------------------------------------------Have you ever had chest pains during exercise?-----------------------------------------------------------------------Have you ever had shortness of breath after mild exertion or been diagnosed with asthma?------------------Have you ever felt dizzy during or immediately following exercise?-----------------------------------------------Have you ever had high/low blood pressure?--------------------------------------------------------------------------Have you ever been told that you have a heart murmur?------------------------------------------------------------Do you have a history of heart disease in your family?-----------------------------------------------------------Has your doctor restricted you from sports because of heart problems?------------------------------------------Have you ever had mononucleosis, myocarditis, or other severe viral infections?-------------------------------Do you have anemia?------------------------------------------------------------------------------------------------------Had hernia?-----------------------------------------------------------------------------------------------------------------Had chicken pox? (What year____?)-----------------------------------------------------------------------------------Do you have epilepsy or convulsions?----------------------------------------------------------------------------------Do you currently have skin problems?----------------------------------------------------------------------------------Have you ever had a concussion?--------------------------------------------------------------------------------------Have you ever had a head injury in which x-rays were required?---------------------------------------------------Have you ever had a seizure?----------------------------------------------------------------------------------------------Do you have frequent or severe headaches?----------------------------------------------------------------------------Had depression/anxiety?---------------------------------------------------------------------------------------------------Have you ever had numbness or tingling in your arms, legs, hands, or feet?-------------------------------------Have you ever had heat exhaustion or heat stroke?--------------------------------------------------------------------Do you wear a corrective or support