University of the Cumberlands
Re-Examination Health History For Returning Athletes

 
Date: UC ID #: Sport: Age:
Name: DOB:
  Last   First     Middle    
Last 4 digits of Social Security #: Email: 
Home Phone #: Cell Phone #:


Year at UC: 

Height Weight Blood Pressure Pulse

Please complete the following form in regard to your physical health since your last medical evaluation for the University of the Cumberlands Intercollegiate Athletics Program. 

 

NOTE:  SINCE YOUR LAST PHYSICAL EXAMINATION: 

1)             Have you had any illness?  If yes please list them: 
             
               

YES

NO

2)             Have you been taking any medications?  If yes please list them: 

               

3)             Have you been hospitalized since your last physical examination?

4)             Have you been unconscious for any reason?

5)             Have you had any dental work done?



6)             Are you now taking any supplements?  If yes, please list:

               

7)             Have you had an injury to any of the following areas:

 

YES

NO

Head

Shoulder

Arm/Hand

Neck

Ribs

Back

 

 

 

 

 
 

YES

NO

Hip

Thigh

Knee

Leg

Ankle

Foot

Other

If you checked yes to any of the orthopaedic questions please explain the injury and action taken: 

 
8)             I have asthma or an EIA and use an inhaler    

9)             I am allergic to insect bites/stings and use an epi-pen

10)             Do you wear contacts/glasses to participate in sports?

11)           Have you had any physical problems since your last physical examination which have not been mentioned?  If yes, please list and explain: 

Daily Medications: (Asthma Inhalers of any kind, allergy shots, Epi-pen for allergic reactions, Blood sugar issues, etc)

 

I do hereby state, to the best of my knowledge and belief, my answers are correct. 

Athlete’s Signature:          Date: