Rockford University Athletics Health History Form – *RETURNING ATHLETES ONLY*

Return to: Lang Center for Health, Wellness and Counseling Rockford University, 5050 East State St., Rockford, IL61108
Phone: / (815) 226-4083 / Fax: / (815) 226-3335 / E-Mail: / / Web: /

INTERCOLLEGIATE ATHLETES - Return to: Athletic Training Office, Rockford University, 5050 East State St., Rockford, IL61108

Phone: / (815) 394-5075 / Fax: / (815) 394-5077 / E-Mail: / / Web: /

NAME______SPORT ______Date of Birth______

Men’s or Women’s

In the past year, have you missed more than 2 consecutive days of participation

in usual activities because of an injuryor have you had an injury that has not resolved? Yes ______No ______

If yes, please explain in detail. Date of injury ______How long were you hurt? ______

Type of injury/specific body part ______

In the past year, have you missed more than 2 consecutive days of participation

in usual activities because of an illness or have you had an illness that has not resolved?Yes ______No______

If yes, please explain in detail. Date of illness ______How long were you sick? ______

Type of illness/treatment ______

In the past year have you had a surgical repair or procedure completed: Yes______No ______

If yes, what body part and side ______

Surgery done ______

Surgery date and physician ______

Have you completed physical therapy or rehabilitation and when ______

Have you been released to participate in intercollegiate athletics?______

By who and when? ______

Restrictions or recommendations from treating physician ______

Have you had a concussion, seizure, or been unconscious for any reason this year?Yes ______No ______

If yes, please explain in detail. ______

Have you had x-rays, MRI, CT scan, surgery or been hospitalized in the last year?Yes ______No ______

If yes, please explain in detail. ______

List all supplements, vitamins, and herbs you are presently taking.

______

List all medications you are presently taking.

______

List all tobacco products you currently use:

______

Do you have any new illnesses or injuries?Yes _____ No ______

If yes, please explain. ______

Are you presently injured or worried about an old injury?Yes _____ No ______

If yes, please explain. ______

Are you allergic to any medications or substances?Yes ______No______

If yes, which one(s)? ______

FEMALES:

When was your last period? ______

In the past year have you gone more than 6 weeks without getting your period? Yes ______No ______

I hereby state that, to the best of my knowledge, my answers to the above questions are correct and complete.

Athlete’s signature ______Date ______