Siena College Sports Medicine Health Questionaire

Please answer the following questions if you are a female student athlete

Menstrual periods regular?   Yes   or   No       Age at onset of menstruation? __________

Days between periods (start to start)? __________       How many days of flow? __________

Date of your last menstrual period? __________       Bleeding between menstrual periods?   Yes   or   No

Are you presently taking birth control pills?   Yes   or   No

If yes, please name the type and length of time that you have been taking them: __________________________________

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Do you do monthly self-breast exams?   Yes   or   No       Family history of breast cancer?   Yes   or   No

Present weight? __________ lbs.       Highest adult weight? __________ lbs.

Do you feel that you are too light or too heavy?   Yes   or   No   Have you ever used laxatives, diuretics or diet pills?  Yes   or   No

Have you ever been treated for an eating disorder?   Yes   or   No

Has anyone in your family ever been treated for an eating disorder?   Yes   or   No

Please answer the following questions if you are a male student athlete

Hernia?   Yes   or   No       Any lumps on testicles?   Yes   or   No       Do you do a monthly self-testicular exam?   Yes   or   No

Present weight? __________ lbs.       Highest adult weight? __________ lbs.

Do you feel that you are too light or too heavy?   Yes   or   No   Have you ever used laxatives, diuretics or diet pills?  Yes   or   No

Have you ever been treated for an eating disorder?   Yes   or   No

Has anyone in your family ever been treated for an eating disorder?   Yes   or   No

Are you currently taking any nutritional supplements?   Yes   or   No

If yes, please list the supplements that you are taking: ____________________________________________________________

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Student-Athlete's Signature: ________________________________________________________     Date: _________________

Go to, Immunization History form.