Recruit Health History Questionnaire Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  Recruit Name

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  Soc.

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  Sport

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  Date of Birth

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  Have you ever suffered a head injury / concussion and/or been knocked unconscious?

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  Have you ever suffered a cervical spine / neck injury?

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  Have you ever suffered a shoulder injury?

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  Have you ever suffered a elbow / forearm, wrist, hand, and/or finger injury?

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  Have you ever suffered a spine, low back, and/or sacroiliac injury?

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  Have you ever suffered a rib, thorax, and/or chest injury?

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  Have you ever suffered a hip, groin, and/or thigh injury?

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  Have you ever suffered a knee injury?

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  Have you ever suffered an ankle, lower leg, and/or foot injury?

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  Have you ever had surgery on your shoulder, elbow / forearm, wrist, hand, and/or finger?

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  Have you ever had surgery on your hip, knee, ankle, lower leg, and/or foot?

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  Have you ever had surgery on your spine (cervical / neck, lumbar, etc.

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  Have you ever suffered a heat-related illness and/or received intravenous fluids (IV) for a heat-...

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  Have you ever been diagnosed with any allergies and/or ever had an unfavorable / allergic reactio...

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  Have you ever been diagnosed with asthma and/or exercised induced asthma?

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  Have you ever been diagnosed with diabetes?

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  Have you ever had chest pain and/or unexplained shortness of breath during or after exercise / pr...

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  Have you ever felt dizzy, lightheaded, and/or passed out during or after exercise / practice?

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  Have you ever had the feeling of your heart racing or skipping beats during or after exercise / p...

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  Have you ever been told that you have a heart murmur?

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  Has any family member or relative died of heart problems and/or of sudden death before age 35?

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  Has a physician ever denied or restricted your participation in sports due to any heart problems?

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  Have you ever had an electrocardiogram (EKG) and/or echocardiogram of your heart?

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  Do you have only one of two paired, functioning organs (eyes, kidney, ovary, etc.

• ...and More!