Sports Questionnaire

Sports Participation History Form
POP WARNER NO LONGER REQUIRES THIS FORM. PLEASE GO ON THE PATIENT PORTAL TO REQUEST THE NEW FORM. DO NOT FILL OUT THIS FORM. There will still be a $15 charge for the new form.
Name of Patient*

First NameLast Name
Date of Birth*

MonthDayYear
Date
What Form are you Requesting?*

PIAA (All Star has this form - do not send)Other Form (You need to email this to forms@allstarpeds.com)
Name of other Form
Which School/Organization is the Form for?*
What sport/activity will the Patient be Participating in?*
Medicines and Allergies
Please list all prescription and over-the-counter medicines and supplements that you are currently taking (If none, please type "NONE")*
Do you have any allergies?*
If yes, please identify specific allergy (check all that apply)

MedicationsPollensFoodStinging InsectsOther
General Questions
1. Has a doctor ever denied or restricted your participation in sports for any reason?*
Explain your "Yes" Answer to Question 1*
2. Do you have any ongoing medical conditions?*
Explain your "Yes" Answer to Question 2
3. Have you ever spent the night in the hospital?*
Explain your "Yes" Answer to Question 3
4. Have you ever had surgery?*
Explain your "Yes" Answer to Question 4
Heart Health Questions About You
5. Have you ever passed out or nearly passed out DURING or AFTER exercise?*
Explain your "Yes" Answer to Question 5
6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?*
Explain your "Yes" Answer to Question 6
7. Does your heart ever race, flutter in your chest or skip beats (irregular beats) during exercise?*
Explain your "Yes" Answer to Question 7
8. Has your doctor ever told you that you have any heart problems (e.g. murmur, high blood pressure)?*
Explain your "Yes" Answer to Question 8
9. Has a doctor ever requested a test for your heart? For example, Electrocardiography (ECG) or echocardiography?*
Explain your "Yes" Answer to Question 9
10. Do you get lightheaded or feel shorter of breath than your friends during exercise?*
Explain your "Yes" Answer to Question 10
11. Have you ever had an unexplained seizure?*
Explain your "Yes" Answer to Question 11
Heart Health Questions About Your Family
12. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)?*
Explain your "Yes" Answer to Question 12
13. Does anyone in your family have a genetic heart problem such as Hypertrophic Cardiomyopathy (HCM), Marfan Syndrome, Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC), long QT Syndrome (LQTS), short QT Syndrome (SQTS), Brugada Syndrome or Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)? *
Explain your "Yes" Answer to Question 13
14. Has anyone in your family had a pacemaker or implanted defibrillator before age 35?*
Explain your "Yes" Answer to Question 14
Bone and Joint Questions
15. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint or tendon that caused you to miss a practice or game?*
Explain your "Yes" Answer to Question 15
16. Do you have a bone, muscle, ligament, or joint injury that bothers you?*
Explain your "Yes" Answer to Question 16
Medical Questions
17. Do you cough, wheeze, or have difficulty breathing during or after exercise?*
Explain your "Yes" Answer to Question 17
18. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? *
Explain your "Yes" Answer to Question 18
19. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?*
Explain your "Yes" Answer to Question 19
20. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus Aureus (MRSA)?*
Explain your "Yes" Answer to Question 20
21. Have you ever had a concussion or a head injury that caused confusion, a prolonged headache,or memory problems? *
Explain your "Yes" Answer to Question 21
22. Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms and legs after being hit or falling? *
Explain your "Yes" Answer to Question 22
23. Have you ever become ill while exercising in the heat?*
Explain your "Yes" Answer to Question 23
24. Do you or someone in your family have sickle cell trait or disease?*
Explain your "Yes" Answer to Question 24
25. Have you ever had or do you have any problems with your eyes or vision?*
Explain your "Yes" Answer to Question 25
26. Do you worry about your weight?*
Explain your "Yes" Answer to Question 26
27. Are you trying to or has anyone recommended that you gain or lose weight?*
Explain your "Yes" Answer to Question 27
28. Are you on a special diet or do you avoid certain types of foods or food groups?*
Explain your "Yes" Answer to Question 28
29. Have you ever had an eating disorder?*
Explain your "Yes" Answer to Question 29
Is the patient sex male or female?
Sex*

MaleFemale
30. Have you ever had a menstrual period?
31. How old were you when you had your first menstrual period?
32. When was you most recent menstrual period?
33. How many periods have you had in the last 12 months?
Signature

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct
Signature*

Clear
Signature of parent (or patient if over 18)
Date*

MonthDayYear
Today's Date
Should be Empty:

Sports Participation History Form

Medicines and Allergies

General Questions

Heart Health Questions About You

Heart Health Questions About Your Family

Bone and Joint Questions

Medical Questions

Is the patient sex male or female?

Signature