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					     Initials:                                      ST. OLAF SPORTS MEDICINE                                            Initials:
    Reviewed by St. Olaf                                 HEALTH HISTORY                                               Reviewed by Examining
       Athletic Trainer                                                                                                       Physician
Participation in intercollegiate athletics requires an acceptance of risk of injury. This form brings pertinent information to the attention of
those involved in the health care of student-athletes. This process is required by the NCAA and must be completed before you will be
permitted to practice or compete in intercollegiate athletics. It will be reviewed by the Athletic Trainers and Team Physician, who will
contact you if there are concerns. Using BLACK INK only, answer the questions by circling the corresponding YES or NO and explaining
all YES responses in the space provided below.

DATE OF BIRTH:                      /         /                                GENDER:            MALE      FEMALE

NAME:                                                                          SPORT(S):

Y N 1a. Have you had a medical illness or injury since your last              Y N 8. Have you ever become ill from exercising in the heat?
        check-up or physical exam?                                            Y N 9a. Do you cough, wheeze, or have trouble breathing during
Y N b. Do you have an ongoing or chronic illness?                                      or after activity?
Y N c. Have you had mononucleosis?                                            Y N b. Do you have asthma?
Y N d. Have you had MRSA (Methillin-Resistant                                 Y N c. Do you have seasonal allergies that require medical
        Staphylococcus Aureus)?                                                        treatment?
Y N 2a. Have you ever been hospitalized overnight?                            Y N 10a. Do you use any special protective or corrective
Y N b. Have you ever had surgery?                                                      equipment devices that aren’t usually used for your sport
Y N 3a. Are you currently taking any prescription or                                   or position (e.g.: knee brace, special neck roll, foot
        nonprescription (over-the-counter) medications or pills                        orthotic, retainer on your teeth, hearing aid)?
        or using an inhaler? LIST BELOW                                       Y N 11a. Have you had any problems with your eyes or vision?
Y N b. Have you ever taken any supplements or vitamins to                     Y N b. Do you wear glasses, contacts, or protective eyewear?
        help you gain or lose weight to improve your                          Y N 12a. Have you ever had a sprain, strain, or swelling after
        performance? LIST BELOW                                                        injury?
Y N 4a. Do you have any allergies (e.g.: pollen, medicine, food,              Y N b. Have you ever broken or fractured any bones or
        stinging insects)?                                                             dislocated any joints?
Y N b. Have you ever had a rash or hives develop during or                    Y N c. Have you ever had any other problems with pain or
        after exercise?                                                                swelling in muscles, tendons, bones, or joints?
Y N 5a. Have you ever passed out during or after exercise?                             If yes, circle appropriate structure and explain:
Y N b. Have you ever been dizzy during or after exercise?                                    Head            Neck          Back      Chest
Y N c. Have you ever had chest pain during or after exercise?                                Shoulder        Upper arm Elbow         Forearm
Y N d. Do you get tired more quickly than your friends do                                    Wrist           Hand          Hip       Thigh
        during exercise?                                                                     Knee            Shin/Calf     Ankle     Foot
Y N e. Have you ever had racing of your heart or skipped                      Y N 13a. Do you want to weigh different than you do now?
        heartbeats?                                                           Y N b. Do you lose weight regularly to meet weight
Y N f. Have you ever had high blood pressure or high                                   requirements for your sport?
        cholesterol?                                                          Y N c. Have you ever been treated for an eating disorder?
Y N g. Have you ever been told you have a heart murmur?                       Y N 14a. Do you feel stressed out?
Y N h. Has any family member or blood relative died of heart                  Y N b. Do you have any sleep problems?
        problems or sudden death before age 50?                               Y N c. Do you have any anxieties?
Y N i. Have you had a severe viral infection (i.e.: myocarditis or            Y N d. Do you have any phobias?
        mononucleosis) within the last month?                                 Y N e. Do you suffer from depression?
Y N j. Has a physician ever denied or restricted your                         Y N f. Do you have worry or nervousness?
        participation in athletics for any heart problems?                    Y N g. Have you had suicidal thoughts?
Y N 6a. Do you have any current skin problems (e.g.: itching,                 Y N 15. Have you had signs or symptoms of Marfans Syndrome?
        rashes, acne, warts, herpes, fungus, or blisters)?                    FEMALES ONLY:
Y N 7a. Have you ever had a head injury or concussion?                        16. a.   When was your first menstrual period?
Y N b. Have you ever been knocked out, become                                     b.   When was your most recent menstrual period?
        unconscious, or lost your memory?                                         c.   How much time do you usually have from the start of one
Y N c. Have you ever had a seizure?                                                    period to the start of another?
Y N d. Do you have frequent or severe headaches?                                  d.   How many periods have you had in the last 12 months?
Y N e. Have you ever had numbness or tingling in your arms,                       e.   What was the longest time between periods in the last 12
        hands, legs, or feet?                                                          months?
Y N f. Have you ever had a stinger, burner, or pinched nerve?

EXPLAIN “YES” ANSWERS HERE, including dates, medical care, and current status (use back if needed):

I do not know of any existing or additional health reason that would preclude participation in NCAA/Intercollegiate Athletics. I certify that
the answers to the above questions are true and accurate. I hereby authorize St. Olaf College Athletic Trainers and Medical Providers to
review the information contained in this document and to disclose to my varsity coaching staff or other appropriate St. Olaf College
representatives the information in this document and any other information they may have about my health and any injuries occurring
while I am a student at St. Olaf College when, in their sole judgment, such information affects my ability to practice or compete.

Student Signature:                                                                                  Date:                /            /


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