Collegiate Athlete Pre-Participation Health Questionnaire
PERSONAL INFORMATION
Full Name
Date of Birth
Sport
Student ID
Year
Freshman
Sophomore
Junior
Senior
Graduate
Email
Phone Number
EMERGENCY CONTACT
Contact Name
Relationship
Contact Phone
MEDICAL HISTORY
Have you ever had surgery?
Yes
No
If yes, please describe
Have you ever had a concussion?
Yes
No
If yes, how many and when?
Have you ever passed out during or after exercise?
Yes
No
If yes, please explain
Do you have any allergies (medicine, food, etc.)?
Yes
No
If yes, please list
Are you currently taking any medication?
Yes
No
If yes, please list
FAMILY HISTORY
Has any family member died before age 50 due to heart disease or other sudden death?
Yes
No
If yes, who and cause
Any family history of heart problems, sickle cell disease, or other major illness?
Yes
No
If yes, please list
OTHER INFORMATION
Please list any other health concerns, injuries, or information relevant to your athletic participation