BJMP Sportsfest 2024

Health Assessment Form

Date: __ ________

Rank/Name: ______ _____________Age: ____ Gender: __ __ Date of Birth: __

Address: __ ___________Jail Unit: ___________

Name Sport(s)_______ _______________________________________________________________

Vital Signs: BP: ___________ Pulse Rate: _______________RR: _____________

A. INJURIES
List X-rays, MRIs, CTs, injections, rehabilitation, physical therapy, brace, cast, etc. and give approximate dates.
 If the injury was within the last 2 years, please provide chart notes and radiology reports

INJURY
None Old Current Approx. Date
o 1. Shoulder/Elbow (e.g., dislocation, rotator cuff, AC separation) ___   ______________
2. Arm/Wrist/Hand/Finger (e.g., fractures) _________________________    ______________
3. Neck (e.g., burners, pinched nerve) ____________________________    ______________
4. Ribs/Abdomen______________________________________________    ______________
5. Low back pain (e.g., herniated disc) ____________________________    ______________
6. Leg/Hip (e.g. Quadriceps, hamstring strain) ______________________    ______________
7. Knee (e.g., ligament, meniscus, patella) _________________________    ______________
8. Lower leg (e.g., shin splints, calf strain) _________________________    ______________
9. Ankle/Calf/Foot/Toe (e.g., sprain, Achille s) ______________________    ______________
10. Stress Fractures ___________________________________________    ______________

Explain: __________________________________________________________________________________

B. SURGERIES List all surgeries and approximate dates.

If surgery was in the past year, provide a summary, copies of surgical notes, and notes that cleared you to
return to your sport.

Type of Surgery______________ ________________________________ Date ___________________

____________________________________________________ Date __________________

C. NEUROLOGICAL ISSUES
Yes No
1. Have you ever had a head injury or concussion? _____________________________________  
If yes, list all dates _____________________________________________________________
Describe any memory loss _______________________________________________________
Describe any problems in the days afterward (e.g. confusion, headache, concentration).
_____________________________________________________________________________
How long did it take you to recover? _______________________________________________
Describe any problems you are still having ___________________________________________
2. Have you been hit in the head and been confused or lost your memory? ___________________  
If yes, describe _________________________________________________________________
3. Have you ever had a seizure (e.g. epilepsy)? If yes, the date of the last seizure _____________  
List all current medications you take to prevent seizures ________________________________
4. Do you have frequent or severe headaches? _________________________________________  
Date last evaluated by the health care provider _______________________________________
List all headache medications that you take __________________________________________
5. Do you have headaches with exercise? ______________________________________________  
6. Have you ever had numbness, tingling, or weakness in your arms
or legs after being hit or falling? __________________________________________________  
7. Have you ever been unable to move your arms or legs after being hit or falling? ____________  
8. Have you been told that you have or have you had an x-ray for
atlantoaxial (neck) instability? ____________________________________________________  
 5. SIGNIFICANT HEALTH ISSUES
Yes No
1. Has a doctor ever denied or restricted your participation in sports for any reason? ____________  
2. Have you ever been hospitalized overnight for reasons other than surgery? _________________  
3. Were you born without or are you missing a kidney, an eye, a testicle, or any other organ? ____  

6. GENERAL MEDICAL ISSUES

Yes No
1. Are there any current prescription medicines or over-the-counter medicines
that you take regularly? (list) ______________________________________________________  
2. Do you have any allergies to medicines? _____________________________________________  
3. Do you have any severe allergies to food or insect stings? _______________________________  
4. Do you have seasonal allergies (hay fever) or other allergies that require medicines? _________  
5. Have you ever had any rash or hives develop during or after exercise? _____________________  
6. Do you cough, wheeze, or have breathing difficulty during or after exercise? ________________  
7. Do you have asthma? ____________________________________________________________  
8. Have you ever used an inhaler, or taken asthma medicine? ______________________________  
9. Is there anyone in your family who has asthma? ______________________________________  
10. Do you have any current skin problems (e.g. athlete’s foot, ringworm, impetigo)? _____________  
11. Have you ever had a herpes skin infection? __________________________________________  
12. Have you had infectious mononucleosis (mono) within the past month? ____________________  
13. When exercising in the heat, do you have severe muscle cramps or become ill? ______________  
14. Do you use any special protective or corrective equipment or devices that aren’t usually
used for your sport or position (e.g., knee brace, special neck roll, foot orthotics, retainer
on your teeth, goggles, face shield, or hearing aid)? ___________________________________  
15. Have you ever had a detached retina or any severe eye trauma? __________________________  
16. Is your vision in either eye worse than 20/40 even with correction (contacts or glasses)? ______  
17. Do you feel significantly stressed or depressed? _______________________________________  
18. If yes, are you taking any medications? (list) __________________________________________  
19. Do you have a history of bleeding disorders such as hemophilia, Von Willebrand disease, or
other factor deficiencies? _________________________________________________________  
20.  If yes, provide documentation.
21. Have you ever been diagnosed with ADD/ADHD? ______________________________________  
22. If yes, are you taking any medications? (list) __________________________________________  
23. Do you have any other ongoing medical problems for which you are being treated
(e.g. anemia, asthma, diabetes, thyroid disorder, etc.)? __________________________________  

A. CARDIOLOGY SCREENING
Yes No
1. Have you ever passed out, or nearly passed out, during or after exercise? If yes, list dates. ___  
2. Have you ever had discomfort, pain or pressure in your chest during exercise? ______________  
3. Does your heart race or skip beats during exercise? __________________________________  
4. Has a doctor ever told you that you have any of the following? If yes, please check all that apply:
 high blood pressure  heart murmur  high cholesterol  heart infection
5. Has a doctor ever ordered a test for your heart? (e.g. ECG, echocardiogram) ________________  
6. Has anyone in your family died for no apparent reason? ________________________________  
7. Has any family member/relative died of heart problems or sudden death before age 50? ______  
8. Has a physician ever denied or restricted your participation in sports for any heart problems? __  
9. Is there any family history of Marfan’s Syndrome, cardiomyopathy or long QT syndrome,
or other heart problems? ____________________________________________________________  

B. WOMEN’S HEALTH (Females only.)

Yes No
1. Have you ever had a menstrual period? ______________________________________________  
2. How old were you when you had your first menstrual period? ____________________________
3. When was your most recent menstrual period? ________________________________________
4. How many periods have you had in the past 12 months? ________________________________
5. Are you presently taking any female hormones (estrogen, progesterone, birth control pills? ____  
6. Do you worry about your weight? __________________________________________________  
 7. Are you trying to, or has anyone recommended that you gain or lose weight? _______________  
8. Are you on a special diet, or do you avoid certain types of food? __________________________  
9. Have you ever taken any supplements to help you gain or lose weight or improve
your performance? ______________________________________________________________  
10. Have you ever had an eating disorder? _______________________________________________  
11. Have you ever had a stress fracture? ________________________________________________  
12. Have you ever been told you have low bone density (osteopenia or osteoporosis)? ___________  

C. MEN’S HEALTH (Males only.)

Yes No
1. Do you worry about your weight? __________________________________________________  
2. Are you trying to, or has anyone recommended that you gain or lose weight? _______________  
3. Are you on a special diet, or do you avoid certain types of food? __________________________  
4. Have you ever had an eating disorder? _______________________________________________  
5. Have you ever taken any supplements to help you gain or lose weight or improve
your performance? _______________________________________________________________  

D. PROVIDE AN EXPLANATION FOR ALL “YES” ANSWERS HERE

____________________________________________________________________________________________
____________________________________________________________________________________________

I verify by my signature my understanding of these items, and that the information I have provided is current and
accurate.

_________________ __________
Signature Over Printed Name

RECOMMENDATION/S: _________________________________________________________________

______________________