Siena College Sports Medicine Health Questionaire

Please circle Yes or No for the following questions

Headaches severe enough to miss a practice or school?   Yes   or   No
History of seizures?   Yes   or   No
History of concussion?   Yes   or   No
Wear glasses or contacts?   Yes   or   No
History of eardrum rupture?   Yes   or   No
Hay fever or allergies?   Yes   or   No
Significant teeth or gum trauma?   Yes   or   No
Shortness of breath during or after exercise?   Yes   or   No
Cough after exercise?   Yes   or   No
Asthma?   Yes   or   No
History of a heart murmur?   Yes   or   No
History of fainting or lightheadedness with exercise?   Yes   or   No
Irregular heartbeats or palpitations?   Yes   or   No
Death of a relative 50 years old from heart disease?   Yes   or   No
History of hypertension?   Yes   or   No
Anemia?   Yes   or   No
Sickle cell trait?   Yes   or   No
Any moles that are big or changing?   Yes   or   No
Family history of melanoma?   Yes   or   No
Any munbness, weakness or tingling of arms, legs or feet?   Yes   or   No
Any muscle atrophy or muscle wasting?   Yes   or   No
Back or neck injury requiring missed game or practice?   Yes   or   No
Joint pain or swelling?   Yes   or   No
Limitation of any joints?   Yes   or   No
Any neck or head injury with extremity of weakness or numbness?   Yes   or   No
Any known spinal defects?   Yes   or   No
Any previous fractures?   Yes   or   No
Any previous history of heat intoleranceor illness?   Yes   or   No
Are you missing any paired organ (eye, lung, kidney, testicle, ovary)?   Yes   or   No
Have you had the chicken pox?   Yes   or   No

Have you had any surgeries?   Yes   or   No   _____________________________________________________________

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Have you ever been hospitalized for an injury or illness?   Yes   or   No   ________________________________________

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