Instructions to Athlete and Parent/Guardian: Please review all questions and answer them to the best of your ability.



<-- 1. Has anyone in the athlete’s family died suddenly before the age of 50 years?
<-- 2. Has the athlete ever passed out during exercise or stopped exercising because of dizziness or chest pain?
<-- 3. Does the athlete have asthma (wheezing), hay fever, other allergies, or carry an EPI pen?
<-- 4. Is the athlete allergic to any medications or bee stings?
<-- 5. Has the athlete ever broken a bone, had to wear a cast, or had an injury to any joint?
<-- 6. Has the athlete ever had a head injury or concussion?
<-- 7. Has the athlete ever had a hit or blow to the head that caused confusion, memory problems, or prolonged headache?
<-- 8. Has the athlete ever suffered a heat‐related illness (heat stroke)?
<-- 9. Does the athlete have a chronic illness or see a physician regularly for any particular problem?
<-- 10. Does the athlete take any prescribed medicine, herbs or nutritional supplements?
<-- 11. Does the athlete have only one of any paired organ (eyes, kidneys, testicles, ovaries, etc.)?
<-- 12. Has the athlete ever had prior limitation from sports participation?
<-- 13. Has the athlete had any episodes of shortness of breath, palpitations, history of rheumatic fever or tiring easily?
<-- 14. Has the athlete ever been diagnosed with a heart murmur or heart condition or hypertension?
<-- 15. Is there a history of young people in the athlete’s family who have had heart disease: examples are cardiomyopathy, abnormal heart rhythms, long QT or Marfan's syndrome?
<-- 16. Has the athlete ever been hospitalized overnight or had surgery?
<-- 17. Does the athlete lose weight regularly to meet the requirements for your sport?
<-- 18. Does the athlete have anything he or she wants to discuss with the physician?
<-- 19. Does the athlete cough, wheeze, or have trouble breathing during or after activity?
<-- 20. Is the athlete unhappy with his or her weight?
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