Health History

SPIRIT OF HOUSTON
2017-2018

As a member of the SPIRIT OF HOUSTON, health is of utmost importance to us.

It is a REQUIREMENT that you complete and submit this Health History EACH YEAR you participate in this ensemble, being very honest and thorough with your responses. This should not take you more than 15-20 minutes.

All information you provide in this health history will be kept in confidence and secured by Dr Bales. The information you provide will only be accessed by the band physician and shared with the band director(s), as is necessary for your best care.

We will do everything possible to accommodate any preexisting health condition to insure a healthy, exciting and educational experience.

All questions with a red * MUST be answered before you can submit this form. There are ample places in this form for you to explain any 'YES' answers and you MUST explain ALL 'YES' answers.

PLEASE, PLEASE follow the format requirements explained under the title line of each question!

YOUR Personal Information

001 LAST - Name*
Capitalize name appropriately... No all caps, please

003 FIRST - Name*
Capitalize name appropriately... No all caps, please

004 MIDDLE - Name
Only if you have one... Capitalize name appropriately... No all caps, please

005 Nick - Name
Only if you have one... Capitalize name appropriately... No all caps, please

006 Gender - Female or Male*

007 Your Ensemble Section*
Please select from drop down list

008 Your Spirit of Houston [SOH] Instrument*
Please select from drop down list. If you are filing for a non-SOH ensemble enter "NONE" and proceed to next question.

109 Proposed or Attained Undergrad Major Degree*
What is your proposed/attained Major Degree, ex: Music Ed, Music Perf, Business, Electrical Eng, MM, DMA etc.

110 Current Classification at UH*
Please select from drop down list

111 If your ensemble is SOH, enter the number of years you have marched SOH, otherwise enter "0"*
If this is your first year enter "0", otherwise enter 1 or 2 or 3, etc.

009 Birth Date*
Format... mm/dd/yyyy

010 Age*

011 Address*
Physical STREET address where you are living while in school

012 Dorm Name/Number or Apartment Number*
DORM Name and Room Number .. or .. Apartment Number

013 City*
Of above address

014 State*
Of above address... Format.... two capitalized letters please

015 Zip Code*
Of above address

016 Your E-mail Address(s)*
Format... separate more than one e-mail with a "space ; space"

017 Your Cell Phone Number*
Format... NNN-NNN-NNNN or enter NONE if you have not phone

YOUR Parent's / Guardian's Information

018 Parent's or Guardian's Names*
Capitalize name appropriately... No all caps, please

019 Parent's or Guardian's Home Street Address*

020 Parent's or Guardian's Home City*

021 Parent's or Guardian's Home State*
Two capitalized letters please

022 Parent's or Guardian's Home Zip Code*

023 Parent's or Guardian's Home Phone Number(s)*
Format... NNN-NNN-NNNN... separate more than one phone number with a "space ; space" or enter NONE

024 Parent's or Guardian's Cell Phone Number(s)*
Format... NNN-NNN-NNNN... separate more than one phone number with a "space ; space" or enter NONE

025 Parent's or Guardian's E-mail Address(s)*
Format... separate more than one e-mail address with a "space ; space" or enter NONE

YOUR Physician's Information

026 Your Physician's Name*
Capitalize name appropriately... No all caps, please
Enter NONE if you have no physician

027 Your Physician's Phone Number*
Format... NNN-NNN-NNNN
Enter NONE if you have no physician or do not know their phone number

YOUR Health History

028 Has a doctor ever denied / restricted your participation in sports for any reason*

029 Do you currently have Asthma*

030 Do you currently have Seizures*

031 Do you currently have Diabetes*

032 Do you currently have any Infections*

033 Do you currently have Anemia*

034 Do you currently have any Allergies*

035 Have you ever spent the night in a hospital*

036 Have you ever had surgery*

037 Are or should you be under a doctor’s care currently*

*01 Explain YES answers in questions: #28-#37

YOUR Heart Health History

038 Have you ever passed out or nearly passed out DURING or AFTER exercise*

039 Have you ever had discomfort, pain, tightness or pressure in your chest DURING or AFTER exercise*

040 Does your heart ever race or skip beats (irregular beats) during exercise*

041 Has anyone ever told you that you have High Blood Pressure*

042 Has anyone ever told you that you have Irregular Heart Beat*

043 Has anyone ever told you that you have Heart Murmur*

*02 Explain YES answers in questions: #38-#43

044 Has anyone ever told you that you had a Heart Infection*

045 Has anyone ever told you that you have High Cholesterol*

046 Has anyone ever told you that you have / had any Other Heart Problems*

047 Has anyone ever ordered a test for your heart, i.e. EKG, MRI or Echocardiogram*

048 Do you frequently feel lightheaded or feel more short of breath than expected during exercise*

049 Have you ever had an unexplained seizure*

050 Do you get tired or short of breath more quickly than your friends during exercise*

*03 Explain YES answers in questions: #44-#50

YOUR Family's Heart Health History

051 Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)*

052 Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long or short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia*

053 Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator*

054 Has anyone in your family had unexplained fainting, seizures or near drowning*

*04 Explain YES answers in questions: #51-#54

Continuation of YOUR Health History

055 Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice, game or event*

056 Have you ever had any broken or fractured bones or dislocated joints*

057 Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, brace, cast or crutches*

058 Have you ever had a stress fracture*

059 Have you ever had an injury that required x-rays or treatment for a neck or spinal problem*

060 Do you regularly use a brace, orthotic, wrap, splint or other assistive device*

061 Do you have a bone, muscle or joint injury that bothers you frequently*

062 Do any of your joints become painful, swollen, feel warm or look red*

*05 Explain YES answers in questions: #55-#62

063 Do you have any history of arthritis or connective tissue disease*

064 Do you use any special protective or corrective equipment or devices (i.e. knee brace, special neck roll, foot orthotics, retainer on your teeth, hearing aid, ear plugs)*

065 Do you cough, wheeze, or have difficulty breathing during or after exercise*

066 Have you ever used an inhaler or taken asthma medicine*

067 Is there anyone in your family who has asthma, allergies, skin disorders or rashes*

068 Do you have seasonal allergies that require medical treatment*

069 Were you born without or are you now missing a kidney, eye, testicle, ovary, spleen or any other organ*

070 Do you have or have you had any gland diorders with your pituitary, thyroid, pancreas, adrenal, testicles, ovaries*

*06 Explain YES answers in questions: #63-#70

071 Have you ever had a kidney disease or infection*

072 Do you have groin pain or a painful bulge or hernia in the groin area*

073 Do you have or have you had any pain or lump in a testicle*
Women should answer NO

074 Do you have or have you had any pain, lump OR leakage in/from a breast*
Both Men and Women should answer either YES or NO

075 Do you have any on going problems with your female organs, infections, bladder problems or menstrual problems*
Men should answer NO

076 Are you on any medications or treatments for menstrual problems*
Men should answer NO

077 Have you had infectious mononucleosis (Mono) within the last year*

078 Do you have any rashes or other skin problems*

*07 Explain YES answers in questions: #71-#78

079 Have you had herpes or MRSA (staph) skin infections*

080 Have you had a hit or blow to the head that caused confusion, prolonged headaches, or memory problems*

081 Do you have a history of a seizure disorder or epilepsy*

082 Do you have headaches with exercise or a history of migraines*

083 Have you ever had numbness, tingling, weakness or unable to move arms or legs after being hit or falling*

084 Have you ever become ill while exercising in the heat*

085 Do you have frequent muscle cramps during or after exercising*

086 Do you take any medicine for diabetes (pills or insulin) or a thyroid condition*

*08 Explain YES answers in questions: #79-#86

087 Are you on any special diet or do you avoid certain foods*
If YES explain in detail below

088 Do you worry about your weight*

089 Are you trying to or has anyone recommended that you gain or lose weight*

090 Do you now have or have you had an eating disorder*

091 Do you now have or have you had any problems with indigestion, stomach (intestinal) ulcers, blood in your stool, constipation or other intestinal problems*

092 Have you ever had hepatitis, liver problems, or yellow jaundice*

093 Do you have a problem with depression or panic attacks*

094 Do you now or have you ever taken any psychiatric medicine*

*09 Explain YES answers in questions: #87-#94

095 Have you ever experienced difficulties with sustaining attention, focus, or concentration*

096 Have you been diagnosed with Attention Deficit Disorder (ADD/ADHD) or taken medications for this*

097 Do you have any problems with your eyes or vision*

098 Do you wear Glasses, Contacts, Both, Neither*

099 Do you have any hearing deficit, tinnitus (ringing in the ear) or other ear problems*

100 Do your or someone in your family have sickle cell trait or anemia*

101 Do you have severe allergies to any drugs, foods, or pollens*
If YES be certain that you list them below

102 Do you have any ongoing dental (teeth), gum infection, braces or other dental pain or problems*

*10 Explain YES answers in questions: #95-#102

103 Do you or have you used alcohol or other recreational drugs*

104 Do you have any concerns that you would like to discuss PRIVATELY with the band physician*
If YES, you might prefer to use the online form linked on the band web page "ASK DOC" for that purpose instead of explaining your concern below. That form is ONLY VIEWED/ACCESSED by the BAND PHYSICIAN. You may also catch him before, during or after rehearsals when he attends.

ALSO -- Please take time to read ALL of the medical information documents posted on the band web page!

*11 Explain YES answers in questions: #103-#104

ALLERGIES and CURRENT MEDICATIONS
It is quite important that you answer the questions below as completely as is possible!

105 List any Drug, Medication, Dietary Supplement, Food, Pollen, etc. to which you have allergies*
Ex: Penicillin, Sulfa, Aspirin, Tylenol, Ibuprofen, Latex Materials, Peanuts, etc.

Separate multiple entries with a semicolon ";" followed by a "space". DO NOT enter each on a separate line.

If you have none, PLEASE enter "NONE"

106 Current Medications or Dietary Supplements*
List all medications (prescription and over-the-counter) or dietary supplements that you CURRENTLY take.

Enter drug/supplement name, dose, and frequency taken.
Separate multiple entries with a semicolon ";" followed by a "space". DO NOT enter each entry on a separate line.

Please enter NONE if you are not regularly taking any medications or dietary supplements.

HEALTH INSURANCE INFORMATION
Please provide your health insurance information in the fields below. It would be quite helpful to have this should you become incapacitated while on a university trip. It would also be helpful to upload a copy of the front and back of your health insurance card - this can be done below.

112 Name of Health Insurance Company

113 Health Insurance Company Phone Number

114 Health Insurance Group Number

115 Health Insurance Individual Number

CONSENT FOR MEDICAL CARE
By selecting the APPROPRIATE statement below (either #1 or #2):

I / We acknowledge to the best of my / our knowledge, the answers to the questions on this form are complete and correct.

As a member of the SPIRIT OF HOUSTON, the student shall engage in practices, travel and performances with their ensemble. I / WE desire that the student receive the proper medical treatment/referral in the event of illness or injury while with the ensemble. I / WE consent to the administration of medical treatments, as may be deemed necessary, for emergency illness/Injury. The staff of the ensemble agrees to promptly notify the parent / guardian, if the student is a minor, in the event of any serious accident or illness.

107 Consent*
Choose either statement 1 or 2 --- which ever applies to you

UPLOAD -- FACE PICTURE and COPY OF HEALTH INSURANCE CARD
PLEASE upload a good quality photo of your face (drivers license/passport type picture). A selfie is just fine, as long as it is focused and taken with good lighting.

ALSO upload a photo of the FRONT AND BACK of your health insurance card.

If you do not have these two items available when filling this form, you may copy AND save the link below and use it later to upload these two items OR return to the band page and select the correct link to upload your photo(s).

https://goo.gl/xtG2ng

File Attachments

We highly recommend that you check the box below and then enter your e-mail address. If you elect to do this, you will receive a copy of this completed form for your personal records; however, this is not mandatory.

Send me a copy of my responses

Email address