Sports Medicine Department &
Brandeis University Health Center

Name
Male    Female
Date of Birth (MM/DD/YYYY)
Grad Year
Dorm/Local Address
Email 
Cell Phone 
Sports Expected to
Participate in 2011-2012

Medical History: The confidential information on this form is made available to the Brandeis University Health Center and the Sports Medicine Department. It may not be released to others without your permission.

No
  Have You Ever…(Questions 1-18) YES/NO Explain all YES answers
1 Been hospitalized or had surgery? Please include dates.

2 Had a chronic illness or recent illness?
3 Had a head injury resulting in unconsciousness or permanent memory loss (concussion)?
4 Fainted during or after exercise?
5 Had wheezing or other serious breathing problems during or after exercise?
6 Had chest pains during or after exercise?

7 Had a neck injury or "stinger" (pins and needles sensation in one or both arms or legs after a head or neck injury)?
8 Been advised to avoid contact sports for any period of time?
9 Experienced racing heart, palpitations, or skipped heart beats?
10 Experienced a "heat" related illness?
11 Used performance enhancing drugs  or supplements?
12 Smoked cigarettes or used chewing tobacco?
13 Used marijuana or other street drugs?
14 Had any of the following medical conditions (please explain in column 4)? A) bleeding disorder, B) asthma, C) anemia, D) high blood pressure, E) cancer, F) herpes-"cold sores", G) rheumatic fever, H) HIV infection, I) heart murmur, J) diabetes, K) sickle cell disease, L) thyroid condition, M) mononucleosis
15 Had a parent, sibling, or other close relative with any of the following problems (please explain in column 4)? A) heart disease or sudden death below age 60, B) high cholesterol, C) phlebitis, D) blood clotting disorder
16 Sprained, dislocated, fractured or had a significant injury to A) head/neck, B) chest/back, C) arm, hand, shoulder, elbow, wrist, D) hip, thigh, knee, E) calf, ankle, foot? Please explain in column 4, including dates and details (i.e. right vs. left)
17 Used protective equipment or braces during exercise? Describe.
18 Had allergic reactions to medicine, food, bee or insect stings?
  PLEASE DESCRIBE THE FOLLOWING IN DETAIL    
19 Do you have a missing or malfunctioning eye, kidney, ovary or testicle?


20 Do you ever wear or need glasses or contact lenses, dental plates or braces?


21 If you answered yes to #20 then answer yes or no. If you need to wear glasses or contact lenses, can your vision be corrected to 20/40 or better in both eyes?
 
22 Have you ever worried that you use alcohol to excess or have a problem controlling your use?



23 Are you presently taking any medication daily or intermittently including inhalers? Please list in column 4.



24 Please list highest and lowest weights since age 15 and your present weight?
Highest weight Age
Lowest weight  Age
Current weight Age
Current height
   
25 Have you ever suspected to been told you might have an eating disorder?
26 Do you eat four servings of dairy a day or take calcium supplements?


27 Do you diet frequently?
  FOR WOMEN ATHLETES ONLY
   
28 At what age was your first menstrual period?     
29 What was the date of your last menstrual period?
Month YR 
   
30 How many menstrual periods have you had in the last twelve months?
   


I allow the Brandeis University Athletic Training and Sports Medicine Staff to obtain any medical information that has been given to Brandeis University Health Center.  (initial)
I agree to have medical insurance equal to or greater than the Medical Coverage offered by Brandeis University. (initial)
I understand that my Medical Insurance is the only insurance coverage I have in the event of an injury sustained while participating in varsity athletics at Brandeis University.  (initial)
NAME
DATE
LAST FOUR DIGITS OF SAGE STUDENT ID #

BY CHECKING THIS BOX, YOU ACKNOWLEDGE THAT ALL THE ABOVE INFORMATION IS CORRECT AND ACCURATE.