Student-Athlete and Family Medical History Checklist

Please print all 2 pages of the form, fill out completely and fax to (518) 783-2992 or mail to:

Check all that apply: Please explain all in the section below.

___ Chicken Pox ___ Back Problems ___ Syncope with exercise
___ German Measles ___ Musculo-skeletal Disorders ___ Kidney Infection
___ Measles ___ Neurological Disorders ___ Kidney Stones
___ Infectious Mononucleosis ___ Seizures Disorders ___ Chronic Kidney Disease
___ Rheumatic Fever ___ Fainting/Dizziness ___ Sexually Transmitted Disease
___ Scarlet Fever ___ Head Injury w/LOC ___ Blood in Urine
___ Anemia ___ Concussion ___ Protein in Urine
___ Bleeding Tendency ___ Heart Conditions ___ Sugar in Urine
___ Changes in Appetite       ___ Marfan's Syndrome ___ Pelvic/Vaginal Infection
___ Changes in Weight       ___ Congenital ___ Hernia
___ Anorexia Nervosa       ___ Murmur ___ Menstrual History
___ Bulimia       ___ Rheumatic Heart       ___ Painful Periods
___ Drug/Alcohol Abuse       ___ Disease       ___ Heavy Flow
___ Steroid Use       ___ Palpitations       ___ Irregular Periods
___ Constipation       ___ Other -- Specify _______________       ___ Age of First Period
___ Diarrhea ___ High Blood Pressure ___ Warts, Moles, Rashes
___ Ulcerative Colitis ___ Low Blood Pressure ___ Eczema
___ Irritable Bowl Syndrome ___ Chest Pain ___ Hives
___ Crohn's Disease ___ High Cholesterol ___ Acne
___ Stomach/Intestinal Problems ___ Asthma ___ Cancer -- Type ____________
___ Jaundice/Liver Disease ___ Hay Fever ___ Diabetes Mellitus
___ Gall Bladder Trouble ___ Pneumonia ___ Hepatitis
___ Pancreatitis ___ Tuberculosis ___ Recurrent Headaches
___ Emotional Illness ___ Bronchitis ___ Migraine Headaches
___ Depression ___ Ear Infections ___ Connective Tissue Disorders
___ Insomnia ___ Cystic Fibrosis ___ Immune Deficiency Disorder
___ panic/Anxiety Attack ___ Sinusitis ___ Gum or Tooth Disorders
___ Joint Disease ___ Bladder Infection ___ Hearing Impairment
___ Bone Fractures ___ Shortness of Breath with exercise ___ Speech Impediment
___ Joint Injury ___ Pregnancy ___ Heat Related Illness
___ Vision Problems ___ Serious Accident/Injury ___ Other: Explain Below

Explanations: _________________________________________________________________________________________

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