Washington Sports Participation Step 1 of 10 10% History FormDate of ExamMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SexAgeGradeSchoolSport(s) Medicines and Allergies:Please list all of the prescription and over‐the‐counter medicines and supplements (herbal and nutritional) that you are currently takingDo you have any allergies? Yes No If yes, please identify specific allergy below. Medicines Pollens Foods Stinging Insects General Questions1. Has a doctor or other health professional ever denied or restricted your participation in sports for any reason?NoYes2. Do you have any ongoing medical conditions?NoYesIf so, please identify below: Asthma Anemia Diabetes Infections Other If other, please list below:3. Have you ever spent the night in the hospital?NoYes4. Have you ever had surgery?NoYes HEART HEALTH QUESTIONS ABOUT YOU 5. Have you ever passed out or nearly passed out DURING or AFTER exercise?NoYes6. Have you ever had discomfort, pain, tightness or pressure in your chest during exercise?NoYes7. Does your heart ever race or skip beats (irregular beats) during exercise?NoYes8. Has a doctor ever told you that you have any heart problems?NoYesIf 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, ECG/EKG, echocardiogram)NoYes10. Do you get lightheaded or feel more short of breath than expected, or get tired more quickly than your friends or classmates during exercise?NoYes11. Have you ever had a seizure?NoYes12. Do you get more tired or short of breath more quickly than your friends during exercise?NoYes HEART HEALTH QUESTIONS ABOUT YOUR FAMILY 13. Has any family member or relative died of heart problems or had an unexpected sudden death before age 50 (including drowning, unexplained car accident or sudden infant death syndrome)?NoYes14. Does anyone in your family have a pacemaker, an implanted defibrillator, or heart problems like hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia?NoYes15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?NoYes16. Has anyone in your family had an unexplained fainting, unexplained seizures, or near drowning?YesNo BONE AND JOINT QUESTIONS17. Have you ever had an injury to a bone, muscle, ligament or tendon that caused you to miss a practice, game or an event?NoYes18. Have you ever had any broken or fractured bones or dislocated joints?NoYes19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?NoYes20. Have you ever had a stress fracture?NoYes21. Have you ever been told that you have or have had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism)NoYes22. Do you regular use a brace, orthotics, or other assistive device?NoYes23. Do you have a bone, muscle or joint problem that bothers you?NoYes24. Do any of your joints become painful, swollen, feel warm, or look red?NoYes25. Do you have any history of juvenile arthritis or connective tissue disease?NoYes MEDICAL QUESTIONS26. Do you cough, wheeze or have difficulty breathing during or after exercise?NoYes27. Have you ever used an inhaler or taken asthma medicine?NoYes28. Is there anyone in your family who has asthma?NoYes29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?NoYes29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?NoYes30. Do you have groin pain or a painful bulge or hernia in a groin area?NoYes31. Have you had infectious mononucleosis (mono) within the last month?NoYes32. Do you have any rashes, pressure sores, or other skin problems?NoYes33. Do you have any rashes, pressure sores, or other skin problems such as herpes or MRSA skin infection?NoYes34. Have you ever had a head injury or concussion?NoYes35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?NoYes36. Do you have a history of seizure disorder?NoYes37. Do you have a history of seizure disorder?NoYes38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?NoYes39. Have you ever been unable to move your arms or legs after being hit or falling?NoYes40. Have you ever become ill while exercising in the heat?NoYes41. Do you get frequent muscle cramps when exercising?NoYes42. Do you or someone in your family have sickle cell trait or disease?NoYes43. Have you had any problems with your eyes or vision?NoYes44. Have you had any eye injuries?NoYes45. Do you wear glasses or contact lenses?NoYes46. Do you wear protective eyewear, such as goggles or a face shield?NoYes47. Do you worry about your weight?NoYes48. Are you trying to or has anyone recommended that you gain or lose weight?NoYes49. Are you on a special diet or do you avoid certain types of food?NoYes50. Have you ever had an eating disorder?NoYes51. Do you have any concerns that you would like to discuss today?NoYes MEDICAL QUESTIONS52. Have you ever had a menstrual period?NoYes53. How old were you when you had your first menstrual period?54. 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 athleteSignature of parent/guardianDateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Δ
