Physical Questionnaire - Guardians Drum and Bugle Corps

If you have any questions, please email us at Info@guardiansyoutharts.org

* All obtained information will be kept confidential and any sections are non-applicable please enter “N/A”

Prospective Member Name Required field

First

Middle

Last

Today's Date

Birth Date

Activity

Sex assigned at birth

How do you identify your gender?

Medical conditions

List past and current medical conditions.

List all past surgical procedures.

Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).

Allergies: List all (e.g., medicines, pollens, food, stinging insects).

Patient Mental Health Questionnaire: Over the last 2 weeks, how often have you been bothered by:

Feeling nervous, anxious, or on edge.

Not being able to stop or control worrying.

Little interest or pleasure in doing things.

Feeling down, depressed, or hopeless.

General Questions: If Yes, explain at the end of this form

Do you have any concerns to discuss with your provider?.

Has a provider ever denied or restricted sports participation?.

Ongoing medical issues or recent illness?

Family Heart Health

Family history of sudden death before age 50.

Genetic heart problems (e.g., HCM, Marfan syndrome, LQTS).

Family member with a pacemaker or defibrillator before age 35.

Medical & Activity Questions

Passed out or nearly passed out during/after exercise.

Chest discomfort, pain, tightness, or pressure during exercise.

Heart racing, fluttering, or skipping beats.

Doctor-diagnosed heart problems or heart tests requested (ECG/Echocardiography).

Light-headedness or unusual shortness of breath during exercise.

History of stress fractures or injuries to bone, muscle, ligament, or joint that caused missed practice/events.

Current bothersome injuries.

History of dislocated joints.

Breathing issues (coughing/wheezing) during exercise.

Missing organs (kidney, eye, spleen, etc.).

Groin/testicle pain or hernia.

Current skin problems (MRSA, rashes, fungus).

Concussions or head injuries (confusion, memory problems).

Numbness, tingling, or weakness in limbs after a fall/hit.

Illness after exercising in heat.

Sickle cell trait or disease.

Vision problems, weight worries, or special diets.

History of eating disorders, migraines, or chronic sinus infections.

Passed sinus Today's

Hospitalizations since last physical.

Explain any "Yes" Answers here.

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct. Signature of participant.

Clear Signature

Signature of parent or guardian (if under 18)

Clear Signature

Date