Allegheny College Athletic Department

Revised: 04/11 ALLEGHENY COLLEGE ATHLETIC DEPARTMENT Date: ______

MEDICAL HISTORY OF ATHLETE

2011-2012 Class Rank Fr So Jr Sr

Last Name ______First Name ______Home Phone ______

Home Address ______City ______State ______Zip ______

Campus Address ______Cell Phone ______Age _____ DOB ______

Sport you will be involved with ______Height ______Weight ______

Emergency contact person ______Phone ______

I. TO BE COMPLETED BY ATHLETE

NO YES Explanation of Yes Answer

1. Are you under a physician’s care? ______

2. Do you now take any medications? ______

3. Have you ever been admitted to a hospital? ______

4. Have you ever had injuries requiring medical attention? ______

5. Have you ever had a surgical operation? ______

6. Do you have any allergies to drugs? ______

7. Do you have any other allergies? (insects, bee stings?) ______

8. Do you wear glasses or contact lenses? ______

9. Have you ever taken any steroids or been on a protein rich diet? ______

10. Have you ever had an illness last more than a week? ______

11. Are you prone to colds, flu, pneumonia? ______

12. Are you prone to infection? (boils) ______

13. Have you ever had any head or neck injuries? ______

14. Have you ever had any shoulder injuries? ______

15. Have you had any hip injuries? ______

16. Have you had any back problems or injuries? ______

17. Have you had any knee injuries? ______

18. Have you had any ankle injuries? ______

19. Are you prone to muscle strains? ______

20. Have you had heat exhaustion or heat stroke? ______

21.  Have you had any neurological problems? (severe headaches,

seizures, fainting) ______

22. Do you have any endocrine disorder? (thyroid, diabetes) ______

Name ______

ALLEGHENY COLLEGE ATHLETIC DEPARTMENT

PRE-PARTICIPATION EXAMINATION

II. TO BE COMPLETED BY EXAMINING PHYSICIAN

1. Date of last Tetanus shot: ______

2.  Brachial blood pressure – sitting: ______

NORMAL ABNORMAL

3. Skin ______

4. HEENT ______

5. Lymphatic ______

6. Respiratory ______

7. Cardiovascular ______

8. Marfan’s Screening ______

9. Musculoskeletal ______

10. Hernia ______

11. GI ______

12. GU ______

13. Neurological ______

14.  Orthopedic

A. Shoulders L ___ L ___

R ___ R ___

B. Knees L ___ L ___

R ___ R ___

LEFT KNEE RIGHT KNEE

NO YES NO YES

1. Laxity of medial collateral ligament ______

2. Laxity of lateral collateral ligament ______

3. Positive anterior drawer sign ______

4. Positive posterior drawer sign ______

5. Meniscus damage of any type ______

C. Ankles L ___ L ___

R ___ R ___

III.  OTHER COMMENTS OR FINDINGS:

Examined and qualified/not qualified for participation in intercollegiate sports. Further studies need to

determine physical eligibility.

______

Health Care Provider’s Signature Date