MSHSL Annual Sports Health Questionnaire

Participant Information (one form per student)

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Parent/Guardian Information

Check Yes or No boxes for each question.

In the last year, has a doctor restricted your student's participation in sports for any reason without clearing you to return to sports? *
In the last year, has your student passed out or nearly passed out during or after exercise? *
In the last year, has your student had discomfort, pain, tightness or pressure in your chest during exercise? *
In the last year, has your student's heart race or skip beats (irregular beats) during exercise? *
In the last year, has your student's gotten light-headed or feel more short of breath than expectted during exercise? *
In the last year, has your student's had an unexplained seizure? *
In the last year, has anyone in your immediate family died suddenly and unexpectedly for no apparent reason? *
In the last year, has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 (including an unexplained drowning or an unexplained car accident)? *
In the last year, has any anyone in your immediate family had instances of unexplained fainting, seizures or near drowning? *
In the last year, has has anyone in your immediate family been diagnosed with hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long or short QT Syndrome, Brugada Syndrome or catecholaminergic polymorphic ventricular tachycardia? *
In the last year, has has anyone in your immediate family under age 35 had a heart problem, pacemaker or implanted defibrillator? *
In the last year, has your student had a head injury or concussion that still has symptoms like continuing headaches, concentration problems or memory problems? *

Additional Information

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