Oregon Sports Participation

History Form

Name

First Last

Date of Birth

Sex

Age

Grade

School

Sport(s)

Medicines and Allergies:

Please list all of the prescription and over‐the‐counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies?

Yes

If yes, please identify specific allergy below.

Medicines

Pollens

Foods

Stinging Insects

Over the last 2 weeks, how often have you been bothered by any of the following problems?
Give answers as 0 to 3, using this scale: 0 = Not at all; 1 = Several days; 2 = More than half the days; 3 = Nearly every day

Little interest or pleasure in doing things:

Feeling down, depressed, or hopeless:

General Questions

1. Do you have any concerns you would like to discuss with your provider?

2. Has a doctor or other health professional ever denied or restricted your participation in sports for any reason?

3. Do you have any ongoing medical conditions?

4. Have you had a COVID-19 infection that required hospitalization?

THESE QUESTIONS LET US KNOW ABOUT THE HEALTH OF YOUR HEART

5. Have you ever passed out or nearly passed out DURING or AFTER exercise?

6. Have you ever had discomfort, pain, tightness or pressure in your chest during exercise?

7. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?

8. Has a doctor ever told you that you have any heart problems?

If so, check all that apply:

High blood pressure

High cholesterol

Kawasaki disease

A heart murmur

A heart infection

Other

If check other, please explain below:

9. Has a doctor ever ordered a test for your heart? For example, electrocardiography (ECG) or echocardiography.

10.Do you get lightheaded or feel shorter of breath than your friends during exercise?

11. Have you ever had a seizure?

THESE QUESTIONS LET US KNOW ABOUT HEART HEALTH IN YOUR FAMILY. PLEASE ANSWER AS BEST YOU CAN.

12. Has any family member or relative died of heart problems or had anunexpected sudden death before age 35 years (including drowning or unexplained car accident)?

13. Does anyone in your family have a genetic heart problem such ashypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (AR VC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia (CPVT)?

14. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?

THESE QUESTIONS LET US KNOW ABOUT ANY BONE OR JOINT PROBLEMS THAT COULD LIMIT YOUR ABILITY TO BE PHYSICALLY ACTIVE.

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?

16. Do you have a bone, muscle, ligament, or joint injury that bothers you?

THESE QUESTIONS LET US KNOW ABOUT ANY CURRENT OR PAST MEDICAL ISSUES

17. Do you cough, wheeze, or have difficulty breathing during/after exercise?

18. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

19. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?

20. Do you have any recurring skin rashes, or rashes that come and go,including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?

21. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?

22. Have you ever had numbness, had tingling, had weakness in your arms or legs or been unable to move your arms or legs after being hit or falling?

23. Have you ever become ill while exercising in the heat?

24. Do you or does someone in your family have sickle cell trait or disease?

25. Have you ever had, or do you have any problems with your eyes or vision?

THESE QUESTIONS LET US KNOW IF YOU ARE PROVIDING YOUR BODY WITH ENOUGH ENERGY (FUEL) WHEN YOU ARE PHYSICALLY ACTIVE

26. Do you worry about your weight?

27. Are you trying to or has anyone recommended that you gain/lose weight?

28. Are you on a special diet or do you avoid certain types of food or foodgroups?

29. Have you ever had an eating disorder?

30. Have you ever had a menstrual period? (If yes, please answer the following questions.)

31. How old were you when you had your first menstrual period?

32. When was your most recent menstrual period?

33. How many periods have you had in the last 12 months?

Explain “yes” answers here:

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

Signature of athlete

Signature of parent/guardian

Date

ORS 336.479, Section 1 (3) "A school district shall require students who continue to participate in extracurricular sports in grades 7 through 12 to have a physical examination once every two years." Section 1(5) “Any physical examination required by this section shall be conducted by a (a) physician possessing an unrestricted license to practice medicine; (b) licensed naturopathic physician; (c) licensed physician assistant; (d) certified nurse practitioner; or a (e) licensed chiropractic physician who has clinical training and experience in detecting cardiopulmonary diseases and defects.”