Pre-Participation Health Questionnaire

University of Ottawa Gee Gees

T D Date : _____/_____/_____ Name: ______________________________________ Female Male

Date of Birth: _____/____/______email: _____________________________________SPORT: ______________________

Area of Study at U of O: _________________________________Year :______________

Home Address: ________________________________________________________________________________________

Street City Province

Family Doctor’s Name: _______________________ Phone No.: _______________________City:____________________

EMERGENCY CONTACT INFORMATION

Name:__________________________________________________________________________________
Relationship to you (parent, sibling) _________________________________________________________
Phone: Cell:_________________Home: __________________ Business: ___________________________

ALL INFORMATION WILL REMAIN CONFIDENTIAL

A) Family History: Has any member of your immediate family (parent, sibling, grandparent) had:
1) Sudden Death before 50? Yes No If yes Who ___________________________________________________________

2) Heart Disease or High Blood Pressure? Yes No If yes Who ________________________________________________

3) Other medical issues? Cancer, Diabetes, Liver disease, Lung disease Other: _______________________________

B) Past Medical History: Have you had any of the following?

1) Heart Murmur Yes No 6) Dizziness—Fainting with exercise Yes No

2) High Blood Pressure Yes No 7) Chest pain or Palpitations Yes No

3) Mononucleosis Yes No 8) Past Surgery or Hospitalization Yes No

4) Epilepsy-Seizures Yes No 9) Asthma Yes No

5) Heat Exhaustion Yes No 10) Other Medical Problems Yes No

If Yes Explain : _______________________________________________________________

Has your Doctor ever restricted your sport participation because of a heart problem? Yes No
If yes to any of these give brief explanation: _______________________________________
Do you cough, wheeze or have trouble breathing before or after activity? Yes No
If yes to any of these give brief explanation: _______________________________________
I have a medical condition I would like to discuss with the doctor Yes No
 C) Immunizations (THIS MUST BE COMPLETED IN FULL): Provide year of last immunization.
Tetanus/Diptheria
Measles/Mumps/Rubella
Hepatitis B
Meningitis
Annual Flu Shot
Yes ______________ No Don’t know ** YOU WILL BE CONTACTED
Yes ______________ No Don’t know
BY THE TEAM DOCTOR TO
PROVIDE APPROPRIATE
Yes ______________ No Don’t know DATES IF NOT PROVIDED/
FILLED OUT/ NO/DON’T
Yes ______________ No Don’t know
KNOW IS CIRCLED
Yes ______________ No Don’t know

Chickenpox (Varicella) Yes ______________ No Don’t know

YOUR PARENTS OR FAMILY DOCTOR SHOULD HAVE THIS INFORMATION

D) Organs:
Do you have any malfunctioning or missing organs? Yes No (ie: kidney, liver, spleen, eye
(vision), ear (hearing), testicle.. )

Other: _____________________________________________________________________
E) Medications and Allergies:
List ANY and EVERY medication and / or supplements you are now taking: (ie: pills, patches, injections, inhaled

Do you have any allergies? Yes No

If Yes WHAT _____________________ Reaction __________________________________

WHAT _____________________Reaction __________________________________

WHAT _____________________Reaction __________________________________

F ) Vision and Dental:
1) Do you wear glasses? Yes No During Sport Yes No

2) Do you wear contacts? Yes No During Sport Yes No

3) Do you have any other Yes No If yes

vision problems?

4) Do you wear a mouth Yes No If yes, how old is it?

guard for sports?

5) Do you have dentures, Yes No If yes

false teeth or braces?

G) Ergogenic Supplements Review:

1) Are you taking any “over the counter” supplements? ( energy boosters, strength builders, vitamins ) Yes / No
if Yes please list __________________________________________________________________

____________________________________________________________________________________
2) Are you presently taking creatine? Yes / No

3) Have you taken creatine in the past? Yes / No if Yes-when _____________________________________

__________________________________________________________________________________________

4) Are you presently taking any substances / supplements containing “ephedrine” Yes / No

5) Have you taken supplements containing “ephedrine” in the past? Yes / No

if Yes— when _________________________________________________________________________

6) Are you taking anything that you are not 100% sure about regarding its contents. Yes / No
if Yes— what is the name ___________________________________________________

7) Are you taking anything that claims to increase your energy or lose weight? Yes / No :

Have you ever taken anything with the above claims? Yes / No

8) Have you taken ever taken ‘anabolic steroids’ Yes / No

if Yes when and type ____________________________________________________________

9) Have you ever taken precursors to anabolic steroids, such as Andro or DHE Yes / No
if Yes when ____________________________________________________________________

10) I would like to know more about the following supplements during the Drug Seminar

a: _______________________b: ____________________________c:_______________________

d: _______________________e: ____________________________f:_______________________

g: _______________________h: ____________________________i:_______________________

11) I prefer to talk about the above matters in private with the Team Physician. Yes / No

12) Are you aware that the CIS has drug testing? Yes / No

The CIS strongly believes that the health and safety of players is vital to maintaining a strong and
vibrant playing environment that is doping free. The CIS is working with the Canadian Centre for
Ethics in Sports to develop an anti-doping policy and players are subject to testing in the pre-
season, regular season and playoffs. Ignorance is not a defense and it is important to realize that
supplements are not regulated products and may contain items from the banned list
(http://www.cces.ca).
* If you are taking anything that you are not 100% sure about regarding its contents
please discuss this with the attending physician.

Signature of Athlete: __________________________________ Date:___________________

H) Female Athlete Review:
1) How old were you when you had your first menstrual period? ______________________
2) How many periods have you had in the past12 months a. 10-12 b. 7-9 c. 5-6 d. 1-6 e. none
3) Have you ever gone for more than 3 months without having a menstrual period? Yes / No
4) Normal duration between periods? _________Days - Your last menstrual period? ___________________
5) Do you take birth control pills or hormones? Yes / No If Yes Name:______________________________
_______________________________________________________________________________________

if Yes reason for taking a. birth control b. regulation of menstrual cycle

6) Have you ever had a PAP test? Yes / No If yes- most recent: __________________

7) Have you ever been treated for anaemia? Yes / No

I ) Lifestyle and Health Issues:

1) Have you had any recent change in weight? Yes No if yes how much ___________ + / -

2) Your Highest weight as an adult _________ Your lowest weight as an adult _________ Height _______

Current weight ________

Are you satisfied with your weight Yes /No :if not, what would you like to weigh? _______________________

3) Have you ever tried to control your weight with: _____ fasting _____ vomiting _____ using laxatives
____ diuretics ____ diet pills ____ Other reason: _________________________________________________

4) Are there certain food groups you avoid. Yes / No If yes Please list_________________________________

__________________________________________________________________________________________

5) Do you have questions about healthy ways to control weight? Yes / No ________________________________

__________________________________________________________________________________________

6 ) Do you have any dietary problems? Yes / No if Yes please outline ___________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

7) Do you consume alcohol on most days? Yes No

8) Do you chew or smoke tobacco? Yes No

9) Have you used any Yes No If Yes when list:

recreational drugs in the
past year?

J) Training History:
1) How old were you when you became active in competitive Sports? __________________________________

2) How many hours do you train for your sport per week ? ___________Hours

3) How many hours do you train beyond normal training times for your sport ( ie on your own time outside of the
structured practice training hours set) ___________Hours per week
K) Head Injury History:
Year Sport Unconscious? How Amnesia How Seen Kept in How long How long Still a Any Tests
Long long By Hospital off off problem CT-MR-EMG
MD Sports School

10

11

12

13

14

15
L) Musculoskeletal Injury History:
Year Diagnosis if known Still a
Left/ Seen by Treatment /
problem
Right MD? Therapy
Y/N

Hand

Wrist

Forearm

Elbow

Upper Arm

Shoulder

Collarbone

Neck

Ribs /
Chest

Mid Back

Low Back

Hip

Thigh

Knee

Ankle

Foot

If there is no enough space, or the injury does not fit any category, write on the back

Athletes Signature: ____________________________________ Date: __________________