1. Form ID number
3. Gender Male Female
4. Academic Class (for the upcoming year)
Freshman Sophomore Junior Senior Co-term (concurrently completing a bachelor's and master's degree) Graduate
6. Varsity sport(s) (Mark with an "x" all that apply, enter a # for years played)
Plan to play # of years played Plan to play # of years played this year at college level this year at college level Baseball Sailing Basketball Soccer Crew Softball Diving Swimming Fencing Synchro. Swimming Field Hockey Tennis Football Track and Field Golf Volleyball Gymnastics Water Polo Lacrosse Wrestling
7. How many years has it been since your last complete health examination, other than an exam that was required for you to participate in sports?
1 Year 2 Years 3 Years >3 Years Never had a complete health exam other than for sports
Yes (if so, please fill out the table below) Name of Medication Dose Frequency of Use No
No
Yes No Specify Allergy: drug or medicine (over the counter or prescribed) foods insects or animals plants, grasses, pollen, dust or other environmental factors other
Yes No Yes No mononucleosis jaundice rubella (German measles) stomach or intestinal ulcer chicken pox hernia repeated sinus infections eczema nose fracture psoriasis hearing defect or loss diabetes recurrent ear infection sickle cell anemia/carrier epilepsy other anemia tumor, growth, cyst, cancer abnormal bleeding or clotting disorder over-active thyroid blood clot or embolism under-active thyroid leukemia or other blood disorder arthritis kidney injury Marfan syndrome other kidney disease oral herpes (cold sores) frequent urinary infections genital herpes depression injury to liver or spleen other mental disorder hepatitis birth defect
11. Have you ever had surgery to the following:
Yes No Date(month/year) If yes, give reason for surgery: eyes / ears/nose/throat / heart / lungs / stomach or bowels/appendix / kidneys / liver/spleen / bone / muscle/ligament/tendon / joint / other (please specify) /
Yes No If no, specify abnormality: eyes ears kidneys
Yes No rash fungal infection cold sore(s)
Yes No
15. During or after exercise, have you ever:
Yes No been dizzy or light- headed? passed out (fainted)? had chest pain, discomfort or tightness? found it more difficult to breath than usual? had problems with coughing?
16. Have you ever been told that you have a heart murmur? Yes No
17. Have you ever had racing of your heart, irregular or skipped beats? Yes No
18. Have you ever been told by a doctor that you have had:
Yes No high blood pressure? pericarditis, myocarditis, endocarditis (infections of the heart)? rheumatic fever? other heart or vascular problems? (please specify)
Yes (if so, specify test and reason below) Test Reason No
Yes No bronchitis? tuberculosis? asthma? wheezing that starts during or just after exercise? pneumothorax (collapsed lung)?
Yes (if so, please complete the table below) How many times? 1x 2x 3x 4x 5x >5x No
Yes (if so, please complete the table below) How many times? 1x 2x 3x 4x 5x >5x What is the longest time that you have been unconscious due to a head injury? A few seconds Up to 5 minutes 6-15 minutes >15 minutes No
24. Have you ever had numbness, tingling, or weakness in your:
Yes No shoulders/arms/hands? buttocks? legs/feet?
26. Have you ever had a seizure? Yes No
27. Do you experience migraine headaches? Yes No
28. Have you ever had a serious eye injury?
Yes (if so, please specify below) No
Yes (if so, please complete the table below) Do you wear glasses or contacts when you train or compete? Yes No Have you had your eyes checked in the past 12 months? Yes No No
31. At what age did your menstrual periods start? years of age
32. When was your most recent menstrual period?
<1 month ago 1-3 months ago 4-6 months ago >6 months ago
33. In the past 12 months:
Yes No have you had trouble with heavy menstrual bleeding? have you had bleeding between periods? have you had menstrual cramps or pain which affected your school or athletic performance? have you had any unusual discharge from your vagina? how many periods have you had? 0 1-3 4-6 7-12 >12 what was the longest time between periods? <1 month 1-3mo 4-6mo >6mo on average how long has each period lasted? 1-5 days 6-10d 11-15d >15d
34. Are you presently taking any female hormones (estrogen, progesterone, birth control pills) for the purpose of regulating your periods? Yes No
35. Have you ever had a pelvic exam / Pap smear?
Yes (if so, please complete the table below) When was your last pelvic exam/PAP smear? <1 yr 1-3 yrs >3 yrs Has your pelvic exam / Pap smear ever been abnormal? Yes No No
36. Were you born with two normal testes? Yes No
37. Have you ever had surgery to remove or repair a testicle(s)? Yes No
38. In the past 12 months have you seen a physician, athletic trainer or other health care professional for a new or ongoing injury?
Yes (if so, please complete the table below) Specify injury(s): Has this injury healed completely? Yes No Yes No Yes No Yes No Yes No No
Yes No a brace, splint, or sleeve? orthotics (shoe inserts)?
Have you ever had or do you currently have an injury or problem of the following: (if you don't know, leave 'No' box marked)
Yes (if so, please specify below) Specify injury(s): Date (month/year): / / / No
never had 1-7 days 8-14 days >14 days Specify injury site or type shin splints traumatic fracture(s) stress fracture(s) tendonitis or tendon injury(s) bursitis sprain pulled muscle(s) back problem(s) ligament injury or tear joint injury(s) or pain other injury other injury other injury
Yes (if so, please specify below) Specify injury(s): Date (month/year): / / No
55. For each full-blood relative listed, please indicate if they have a history of the following (do not include adoptive, step, or foster relatives) (Place an 'x' in all boxes that apply; mark 'No history in family' if appropriate or if family history unknown):
No history in family Mother/Father Brother/Sister Grandparent high blood pressure heart attack other heart abnormalities high blood cholesterol diabetes arthritis bleeding disorder Marfan syndrome kidney disease mental illness sickle cell anemia epilepsy cancer
Yes (if known, please specify reason below) No
Native American / Alaska native Hispanic/Latino/Chicano Asian White (non-Hispanic) Pacific Islander Other, specify: Black/African American Don't know
58. What is your current: weight (in lbs) and height (in inches)?
59. Are you happy with your current weight? Yes No
60. What would be your ideal weight? lbs
61. Are you happy with your body build or proportion? Yes No
62. Do you avoid eating any of the following foods?
Yes No Meat Bread/Grains Dairy Products Vegetables Fruits Other Foods (please specify)
63. Would you like to speak to a physician or nutritionist about healthy ways to control your weight?
64. How often do you:
Never Rarely Sometimes Often Always fall asleep in class? have a difficult time waking up in the morning and/or in time for class? experience insomnia (sleeplessness) to the point that it affects your daytime performance in school and/or sports?
never rarely sometimes often always never had to train or compete after flying across one or more time zones
67. On average, how many minutes does it take you to fall asleep at night?
<1 minute 1-5 minutes 6-10 minutes 11-20 minutes 21-30 minutes >30 minutes
<4 hours 4-5 hours 6-7 hours 8-9 hours 10-11 hours >11 hours
Yes (Complete Question #70) No (Skip to Question #71)
Yes (please complete the table below) How many years have you smoked? years About how many cigarettes do you smoke per day? cigarettes No (please complete the table below) How many years did you smoke? years About how many cigarettes did you smoke per day? cigarettes When did you last smoke? <6 months ago 6 months-1 year ago 1-5 years ago >5 years ago
No (please complete the table below)
72. Do you presently drink the following:
BEVERAGE ONESERVING Never or<1 Per Month 1-3Per Month 1Per Week 2-4Per Week 5-6Per Week 1Per Day 2-3Per Day 4-5Per Day 6+Per Day Beer 12 oz canor bottle Wine or wine coolers 1 mediumglass Liquor 1 shot
74. Have you ever tried to control your weight with:
Yes No fasting? vomiting? laxatives? diuretics? diet pills?
76. How often do you wear a seat belt when driving or riding in a vehicle?
never rarely sometimes often always don't drive
within 5 mph of limit 6-10 mph over limit 11-15 mph over limit more than 15 mph over limit don't drive
never rarely sometimes often always don't ride a bicycle
never rarely sometimes often always don't ride a scooter/motorcycle
81. Below is a list of words that describe feelings people have. Please read each one carefully. Then circle the answer to the right which best describes HOW YOU HAVE BEEN FEELING DURING THE PAST MONTH INCLUDING TODAY.
The numbers refer to these phrases: 0 = Not at all 1 = A little 2 = Moderately 3 = Quite a bit 4 = Extremely Friendly 0 1 2 3 4 Nervous 0 1 2 3 4 Tense 0 1 2 3 4 Lonely 0 1 2 3 4 Angry 0 1 2 3 4 Miserable 0 1 2 3 4 Worn Out 0 1 2 3 4 Muddled 0 1 2 3 4 Unhappy 0 1 2 3 4 Cheerful 0 1 2 3 4 Clear- headed 0 1 2 3 4 Bitter 0 1 2 3 4 Lively 0 1 2 3 4 Exhausted 0 1 2 3 4 Confused 0 1 2 3 4 Anxious 0 1 2 3 4 Sorry for things done 0 1 2 3 4 Ready to fight 0 1 2 3 4 Shaky 0 1 2 3 4 Good natured 0 1 2 3 4 Listless 0 1 2 3 4 Gloomy 0 1 2 3 4 Peeved 0 1 2 3 4 Desperate 0 1 2 3 4 Considerate 0 1 2 3 4 Sluggish 0 1 2 3 4 0 = Not at all 1 = A little 2 = Moderately 3 = Quite a bit 4 = Extremely Sad 0 1 2 3 4 Rebellious 0 1 2 3 4 Active 0 1 2 3 4 Helpless 0 1 2 3 4 On edge 0 1 2 3 4 Weary 0 1 2 3 4 Grouchy 0 1 2 3 4 Bewildered 0 1 2 3 4 Blue 0 1 2 3 4 Alert 0 1 2 3 4 Energetic 0 1 2 3 4 Deceived 0 1 2 3 4 Panicky 0 1 2 3 4 Furious 0 1 2 3 4 Hopeless 0 1 2 3 4 Efficient 0 1 2 3 4 Relaxed 0 1 2 3 4 Trusting 0 1 2 3 4 Unworthy 0 1 2 3 4 Full of pep 0 1 2 3 4 Spiteful 0 1 2 3 4 Bad- tempered 0 1 2 3 4 Sympathetic 0 1 2 3 4 Worthless 0 1 2 3 4 Uneasy 0 1 2 3 4 Forgetful 0 1 2 3 4 0 = Not at all 1 = A little 2 = Moderately 3 = Quite a bit 4 = Extremely Restless 0 1 2 3 4 Carefree 0 1 2 3 4 Unable to concentrate 0 1 2 3 4 Terrified 0 1 2 3 4 Fatigued 0 1 2 3 4 Guilty 0 1 2 3 4 Helpful 0 1 2 3 4 Vigorous 0 1 2 3 4 Annoyed 0 1 2 3 4 Uncertain about things 0 1 2 3 4 Discouraged 0 1 2 3 4 Bushed 0 1 2 3 4 Resentful 0 1 2 3 4
0 = Not at all 1 = A little 2 = Moderately 3 = Quite a bit 4 = Extremely
Yes No stress? depression? other health concerns?
83. This is the second year that an Internet format has been used for the pre-participation exam. Approximately how long did it take you to complete the questionnaire? minutes
84. How did you find this Internet format in terms of ease of access to the web page questionnaire?
easy to access moderately difficult to access difficult to access
85. How did you find this Internet format in terms of ease of completion of the web page questionnaire?
easy to complete moderately difficult to complete difficult to complete
Your medical information is being submitted with an assigned number which is known only to the sports medicine staff at Stanford University. You have not entered your name on this questionnaire. Therefore your information cannot be identified by anyone except the sports medicine staff and your privacy is not at risk.
