MSHSL ANNUAL SPORTS HEALTH QUESTIONNAIRE FORM

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MSHSL ANNUAL SPORTS HEALTH QUESTIONNAIRE
DATE
_____ / ______ / __________
Name ______________________________________
Grade ___
Male
School ________________________________
Female
Age _____
Birth Date ______ / ______ / _________
Sport(s) ______________________________________________
Address ___________________________________________________________________________________________________
Phone
___________________________
Date of Last Sports Qualifying Physical Exam (SQPE) ______ / ______ / _________
Check Yes or No boxes for each question or Circle question numbers for which you cannot answer.
IN THE LAST YEAR, since your last complete Sports Qualifying Physical Exam with your physician or your Year 2 Annual Health
Questionnaire, HAVE YOU HAD ANY CHANGES TO THE FOLLOWING QUESTIONS:
YES
NO
1. In the last year, has a doctor restricted your participation in sports for any reason without clearing you to return to sports? ..............
IMPORTANT HEART HEALTH QUESTIONS ABOUT YOU IN THE LAST YEAR
2. In the last year, have you passed out or nearly passed out during or after exercise? .........................................................................
3. In the last year, have you had discomfort, pain, tightness, or pressure in your chest during exercise? ...............................................
4. In the last year, does your heart race or skip beats (irregular beats) during exercise? .......................................................................
5. In the last year, do you get light-headed or feel more short of breath than expected during exercise? ...............................................
6. In the last year, have you had an unexplained seizure? .....................................................................................................................
IMPORTANT HEART HEALTH QUESTIONS ABOUT YOUR FAMILY IN THE LAST YEAR
7. In the last year, has anyone in your immediate family died suddenly and unexpectedly for no apparent reason? ..............................
8. In the last year, has any family member or relative died of heart problems or had an unexpected or unexplained sudden death
before age 50 (including an unexplained drowning, an unexplained car accident, or Sudden Infant Death Syndrome)? ....................
9. In the last year, has anyone in your immediate family had instances of unexplained fainting, seizures, or near drowning? ................
10. In the last year, has anyone in your immediate family developed hypertrophic cardiomyopathy, Marfan Syndrome, arrhythmogenic
right ventricular cardiomyopathy, long QT Syndrome, short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic
ventricular tachycardia? .....................................................................................................................................................................
11. In the last year, has anyone in your immediate family been diagnosed with Marfan Syndrome, arrhythmogenic right ventricular
cardiomyopathy,long or short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic ventricular tachycardia? .........
12. In the last year, has anyone in your immediate family under age 50 had a heart problem, pacemaker, or implanted defibrillator? .....
MEDICAL RISK QUESTIONS IN THE LAST YEAR
13. Have you had infectious mononucleosis (mono) within the last month? .............................................................................................
14. In the last year, have you had a head injury or concussion that still has symptoms like continuing headaches? ................................
15. In the last year, have you had numbness, tingling, weakness in, or inability to move your arms or legs after being hit or falling?.......
Parents or Legal Guardians: Please note below any health concerns, medications, or allergies that may be important
for the coaches or athletic/activities director to know.
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
I do not know of any existing physical or additional health reason that would preclude participation in sports. I certify that the answers to the above
questions are true and accurate and I approve participation in athletic activities.
_______________________________________________
Parent or Legal Guardian Signature
________________________________________________
Athlete Signature
__________________
Date
Athletic/Activity Director Notes: (a YES answer to any of the questions above
requires a clearance note from a physician prior to participation.)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
SQPE Due _____ / _____ / _______
CLEARED FOR SPORTS: YES
NO
Reference: Preparticipation Physical Evaluation (Third Edition): AAFP, AAP, AMSSM, AOSSM, AOASM ; McGraw-Hill, 2004.
Revised 9/4/2009
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