Sex assigned at birth (F, M, or intersex):
How do you identify your gender? (F, M, or other):
Patient Health Questionnaire Version 4 (PHQ-4) Over the last 2 weeks, how often have you been bothered by any of the following problems? ( checkbox next to appropriate number)
(A sum of > 3 is considered positive on either subscale [questions l and 2, or questions 3 and 4] for screening purposes.)
Medical Questions
Do you have any concerns that you would like to discuss with your provider?
Has a provider ever denied or restricted your participation in sports for any reason?
Yes No
Do you have any ongoing medical issues or recent illness?
Yes No
Have, you ever passed out or nearly passed out during or after exercise?
Yes No
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
Yes No
Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?
Yes No
Has a doctor ever told you that you have any heart problems?
Yes No
Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG)
Yes No
Do you get light-headed or feel shorter of breath than your friends during exercise?
Yes No
Have you ever had a seizure?
Yes No
Has any family member or relative died of heart problems or had on unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)?
Yes No
Does anyone in your family have a genetic heart problem such as hypertrophic cordiomyopothy □ (HCM), Morfon syndrome, arrhythmogenic right ventricular cardiomyopathy (ARV(), long QT syndrome (LQTS), short QT syndrome {SQTS), Brugodo syndrome, or catecholominergic poly-morphic ventricular tachycardia (CPVT)?
Yes No
Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?
Yes No
Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game?
Yes No
Do you have a bone, muscle, ligament, or joint injury that bothers you?
Yes No
Do you cough, wheeze, or have difficulty breathing during or after exercise?
Yes No
Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
Yes No
Do you have groin or testicle pain or a painful bulge or hernia in the groin area?
Yes No
Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus
(MRSA)?
Yes No
Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?
Yes No
Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms after being hit or falling?
Yes No
Have you ever become ill after exercising in the heat?
Yes No
Do you or does someone in your family have sickle cell trait or disease?
Yes No
Have you ever had or do you have any problems with your eyes or vision?
Yes No
I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.
Signature of athlete:
Signature of parent or guardian: