University of Pittsburgh wheelccc

Please indicate if you have ever had any of the following: Yes No Atlantoaxial instability X-ray evaluation for atlantoaxial instability Dislocated joints (more than one) Easy bleeding Enlarged spleen Hepatitis Osteopenia or osteoporosis Difficulty controlling bowel Difficulty controlling bladder Numbness or tingling in arms or hands Numbness or tingling in legs or feet Weakness in arms or hands Weakness in legs or feet Recent change in coordination Recent change in ability to walk Spina bifida Latex allergy Explain “yes” answers here: I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of athlete: __________________________________________ Signature of parent/guardian (if under 18 years of age): _____________________________ Date: _____________________ ©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteo- pathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. 20

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