Student-Athlete Medical History
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Student Athlete's First Name  *
Student Athlete's Last Name  *
Sport *
Do you have or have you been told you have any of the following?  *
Yes
No
Asthma/Exercise Induced Asthma?
Mononucleosis?
Diabetes?
Excessive Fatigue with Exercise?
Concussion/Loss of Consciousness?
Chest Pain, Discomfort, or Palpitations?
Excessive or unexpected shortness of breath with exercise?
History of heart murmur?
Family history of sudden death or someone in the family?
Family history of Martan's disease?
MEN: Hernia or Hernia Surgery?
Heat Related Illness (Exahustation/Stroke)?
Epilepsy/Seizures?
Nose Bleeds?
Exposure to tuberculosis (TB), HIV, Hepatitis
Sickle Cell Disease?
Fainting spells or dizziness with exercise?
Loss of/impaired-organ function (eye, kidney, testicle, spleen)
Elevated blood pressure?
Family History of Severe Cardiac Disease or Heart Condition?
Women: Positive pregnancy test in the last year?
List any orthopedic injuries within the past 2 years
Yes
No
Date
Comment
Head/Neck
Back
Shoulder
Arm/Elbow
Hand/Wrist
Knee/Ankle
Other
Nutrition, Drugs, Food Supplements, and Miscellaneous Agents. Have you ever used any of the following:
Never
Occassionally
Frequently
Stimulants (Benzedine, Amphetamines, etc)?
Chewing Tobacco, Snuff, Smokeless Tobacco
Cigarettes, Cigars or Pipe
Vitamis
Diet Pills
Alcoholic Beverages
Amino Acids (Energy Drinks)
Any other diet, nutritional or performance drugs
I certify that all the above information is true and accurate to the best of my knowledge. I have no abnormality, limitation, or restriction not mentioned in this record. I understand that this record is to help determine my fitness to participate in collegiate athletics and to aid in the treatment and diagnosis of future injuries/illnesses that may occur as a result of athletic activities with the UIC Eagle Rays. 
Student-Athlete Electronic Signature  *
Date  *
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DD
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YYYY
Student-Athlete Parent/Guardian Electronic Signature (Required if participant is under the age of 18)
Date 
MM
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YYYY
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