Final PPE Form V2 (16 March) Getting StartedAllergiesGeneral Questions First Name Last Name Date of Birth Date of Examination Sex assigned at birth (F, M, or intersex) Male FemaleHow do you identify your gender? (F/M/other) Age Sport Sport - Select -SoccerFootball (line)Football (other)Racket sportBasketballBaseball/softballwrestling/weight liftingGymnasticsSwimmingWater poloTrack and fieldCross countryDistance runningField hockey/LacrosseCrewPreviousNextHave You Had Covid-19? Yes NoHave You Been Immunized For Covid-19? Yes NoIf Yes, How many shots have you had? 1 Shot 2 shots 3 ShotsBooster Date (if applicable) Please List Any Past and Current Medical Conditions Have You Ever Had Surgery? If Yes, Please List All Past Surgical Procedures Medicines and Supplements: List all current prescriptions, over the counter medicines, and supplements (herbal and nutritional) Do You Have Any Allergies? Yes NoPlease list any medicinal allergies you have (if applicable) Please list any specific food allergies (if applicable) Please list any specific pollen allergies (if applicable) Please list any specific stinging insect allergies (if applicable) PreviousNextOver the last two weeks, how often have you been bothered by any of the following problemsNot At AllSeveral DaysOver Half the DaysNearly Every DayFeeling nervous, anxious, or on edgeNot being able to stop or control worryingLittle Interest or Pleasure in Doing ThingsFeeling Down, Depressed or HelplessDo You have any concerns that you would like to discuss with your provider? Yes NoHas a doctor ever denied or restricted your participation in sports for any reason? Yes NoDo you have any ongoing medical conditions or recent illness? If so, please identify below SelectAsthmaAnemiaDiabetesOtherHave you ever passed out or nearly passed out during or after exercise? (Please watch the video below) Yes No Have you ever had discomfort pain tightness or pressure in your chest during exercise? (Please watch the video below) Yes No Does your heart ever race or flutter in your chest or skip irregular beats during exercise? (Please watch the video below) Yes No Has a doctor ever told you that you have any heart problems? Yes NoHas a doctor ever requested a test for your heart for example electrocardiography (ECG) or echocardiography? Yes NoDo you get light-headed or feel shorter of breath than your friends during exercise? (Please watch the video below) Yes No Have you ever had a seizure? Yes NoHas any family member has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years including drowning or unexplained car crash? Yes NoDoes anyone in your family have a genetic heart problem or a history of heart disease? If yes please list the family member (i.e mother, father, brother, sister etc) SelectAsthmaAnemiaDiabetesOtherHas anyone in your family had a pacemaker or an implanted defibrillator before age 35? Yes No Previous Submit Form
