2013/2014 MSHSL Sports Health Questionnaire

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Athletic/Activity Director Notes: (a YES answer to any of the questions below requires a clearance note from a physician prior to participation.)

IN THE LAST YEAR, since your last complete Sports Qualifying Physical Exam with your physician or your Year 2 Annual Health Questionnaire, HAVE YOU HAD ANY CHANGES TO THE FOLLOWING QUESTIONS:

In the last year, has a doctor restricted your participation in sports for any reason without clearing you to return to sports?

Yes

In the last year, have you passed out or nearly passed out during or after exercise?

Yes

In the last year, have you had discomfort, pain, tightness, or pressure in your chest during exercise?

Yes

In the last year, does your heart race or skip beats (irregular beats) during exercise?

Yes

In the last year, do you get light-headed or feel more short of breath than expected during exercise?

Yes

In the last year, have you had an unexplained seizure?

Yes

In the last year, has anyone in your immediate family died suddenly and unexpectedly for no apparent reason?

Yes

In the last year, has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including an unexplained drowning, an unexplained car accident, or Sudden Infant Death Syndrome)?

Yes

In the last year, has anyone in your immediate family had instances of unexplained fainting, seizures, or near drowning?

Yes

In the last year, has anyone in your immediate family developed hypertrophic cardiomyopathy, Marfan Syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT Syndrome, short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic ventricular tachycardia?

Yes

In the last year, has anyone in your immediate family been diagnosed with Marfan Syndrome, arrhythmogenic right ventricular cardiomyopathy,long or short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic ventricular tachycardia?

Yes

In the last year, has anyone in your immediate family under age 50 had a heart problem, pacemaker, or implanted defibrillator?

Yes

Have you had infectious mononucleosis (mono) within the last month?

Yes

In the last year, have you had a head injury or concussion that still has symptoms like continuing headaches?

Yes

In the last year, have you had numbness, tingling, weakness in, or inability to move your arms or legs after being hit or falling?

Yes

Student's Electronic Signature

Date of Student's Electronic Signature

Parent/Guardian Electronic Signature

Date of Parent/Guardian Electronic Signature

312 7th Ave. N.
St. Cloud, MN 56303

Main: 320-251-3421

Emmett Keenan
(320) 257-2130

Julie Murphy
(320) 257-2120

Denise Klein
(320) 257-2117

Cathedral Crusaders
Online Registration

2013/2014 MSHSL Sports Health Questionnaire

Choose "Yes" or "No" for each question.

Cathedral High School

Activities Office

Enrollment

Cathedral CrusadersOnline Registration

2013/2014 MSHSL Sports Health Questionnaire

Choose "Yes" or "No" for each question.

Cathedral High School

Activities Office

Enrollment

Cathedral Crusaders
Online Registration