2021 ~ 2022 MSHSL Annual Sports Health Questionnaire

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Reference: Preparticipation Physical Evaluation (Fifth Edition): AAFP, AAP, AMSSM, AOSSM, AOASM ; AAP, 2010.
Revised 4/9/2021

Email *

Date: *

YYYY

Name: *

Age: *

Birth Date: *

YYYY

Grade: *

Date of Last Sports Qualifying Physical Exam: *

YYYY

Contact Information

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:

In the last year, has a doctor restricted your participation in sports for any reason without clearing you to return to sports? *

Yes

Required

IMPORTANT HEART HEALTH QUESTIONS ABOUT YOU IN THE LAST YEAR

In the last year, have you passed out or nearly passed out during or after exercise? *

Yes

Required

In the last year, have you had discomfort, pain, tightness, or pressure in your chest during exercise? *

Yes

Required

In the last year, does your heart race or skip beats (irregular beats) during exercise? *

Yes

Required

In the last year, do you get light-headed or feel more short of breath than expected during exercise? *

Yes

Required

In the last year, have you had an unexplained seizure? *

Yes

Required

IMPORTANT HEART HEALTH QUESTIONS ABOUT YOUR FAMILY IN THE LAST YEAR

In the last year, has anyone in your immediate family died suddenly and unexpectedly for no apparent reason? *

Yes

Required

In the last year, has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 (including an unexplained drowning or an unexplained car accident)? *

Yes

Required

In the last year, has anyone in your immediate family had instances of unexplained fainting, seizures, or near drowning? *

Yes

Required

In the last year, has anyone in your immediate family been diagnosed with hypertrophic cardiomyopathy, Marfan Syndrome, arrhythmogenic right ventricular cardiomyopathy, long or short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphicventricular tachycardia? *

Yes

Required

In the last year, has anyone in your immediate family under age 35 had a heart problem, pacemaker, or implanted defibrillator *

Yes

Required

In the last year, have you had a head injury or concussion that still has symptoms like continuing headaches, concentration problemsor memory problems? *

Yes

Required

Parents or Legal Guardians: Please note below any health concerns, medications, or allergies that may be importantfor 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 Typed Signature with date: * *

Supplemental Mental Health Screening Questions (If the sum of responses to questions 1 & 2 or 3 & 4 are ≥3, please see your provider) *

Not at all

Several days

Over half the days

Nearly every day

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

Little interest or pleasure in doing thingsRow 3

Feeling down, depressed, or hopeless

Send me a copy of my responses.

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