File # _______

McGill Sport Medicine Clinic

Physical Examination
for Returning Athletes

Last Name: ________________________________________ Date: ___________

First Name: _________________________

Sport: __________________ Position/Event: _________________

Student ID _____________________

Medicare Number: _________________________ Expiry: ____/____ Prov: _________

OR
Blue Cross: Contract No. ________________ Certificate No. ___________________

Montreal Address: _________________________________________________________

_______________________________ Postal Code: _____________

Home Phone: (_____)______________________ Cell: (______)_________________

E-mail: ________________________________________________________

Emergency Contact:

Name: _______________________________ Relationship to you: _________________

Phone: (_____)_________________________

Have you opted out of the SSMU / PGSS Health plan? No O Yes O (not recommended)

General
Yes No
Since your last medical evaluation here at the McGill Sport Medicine Clinic, have you:

1) suffered any new musculo-skeletal injuries ?................................................................................. O O

2) felt symptoms from previous injuries? ........................................................................................... O O
3) consulted a physician for any condition? ...................................................................................... O O
4) been hospitalized for any condition? ............................................................................................. O O
5) discovered you suffer from any current/new allergies? ................................................................. O O
6) started using any current/new medications? ................................................................................. O O
7) started using any new dietary supplements? ................................................................................ O O
8) started using any new vitamins or minerals? ................................................................................. O O
9) been told that a close family member suffers from a medical condition that concerns you? ........ O O
10) started using a new piece of protective equipment? .................................................................... O O
11) felt the need to consult an eye doctor? ........................................................................................ O O
a dentist?........................................................................................ O O
a physio/athletic therapist?................................................ O O
12) started practising a new sport?… …………………………………………………………………… O O

Do you have any concerns you would like to discuss with one of our doctors?...................................

.........................................................................................................................................................................

Comments:………………………………………………………………………………………………..
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Head Injuries Yes No

1. Have you ever had a concussion? ................................................................................................ O O

Number of times _____
2. After being hit, have you ever had memory loss ............................................................................ O O
Number of times _____
3. After being hit, have you ever been unconscious?......................................................................... O O
Number of times _____
4. After being hit, have you ever had recurrent headaches? .............................................................. O O
5. Have you ever been hospitalized after a head injury? .................................................................... O O
6. Have you ever refrained from participation due to a head injury?................................................... O O
7. Have you ever had a seizure?........................................................................................... O O

For Female Athletes

Yes No
1. How old were you when you had your first menstrual period? _____
2. Did you miss a menstrual period last year? ................................................................................. O O
3. Are you on the birth control pill? ...................................................................................... O O

General

1. Are you happy with your weight? ................................................................................................. O O

2. Are you on a diet? ........................................................................................................................ O O
3. Are you a vegetarian? .................................................................................................................. O O
4. Do you eat three meals per day? .................................................................................................. O O
5. Do you smoke? ............................................................................................................................. O O
6. Do you drink alcohol? ................................................................................................................... O O
7. Do you drink caffeine or cola? ........................................................................................................ O O
8. Do you use drugs? ......................................................................................................................... O O
9. Do you use laxatives or diuretics? .................................................................................................. O O
10. Have you undergone a weight loss recently?................................................................................ O O
11. Have your athletic performances declined? ................................................................................. O O
12. Have you ever suffered a stress fracture? ................................................................................... O O
13. Do you feel cold, even in warm environments? ............................................................................ O O
14. Are you often constipated?............................................................................................................ O O
15. Do you feel lightheaded or fatigued?............................................................................................. O O
16. Do you have difficulty concentrating? ........................................................................................... O O
17. Do you feel depressed? ................................................................................................................ O O
18. Have you ever been diagnosed with an eating disorder? ............................................................. O O

Comments .....................................................................................................................................................

…………………………………………………………………………………………………………………………..

Cardiovascular Yes No

1. Has anyone in your family died of heart problems?

or sudden death before age 50? ............................................................................................... O O
2. Have you ever been dizzy or passed out during exercise?............................................................ O O
3. Do you get tired more quickly than your friends during exercise? ................................................. O O
4. Have you ever had chest pain during exercise? ............................................................................ O O
5. Have you ever been told you had a heart murmur? ....................................................................... O O
6. Have you ever had a racing heart or a skipped beat? ................................................................... O O
7. Have you ever had high blood pressure or high cholesterol? ........................................................ O O
8. Have you had a severe viral infection (e.g. mononucleosis, myocarditis)? ................................... O O
9. Have any of your relatives had cardiomyopathy, Marfan’s syndrome or
a significant heart arrhythmia? ................................................................................................. O O
10. Has a physician previously limited your participation in athletics?............................................... O O

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Consent

a) General

• I agree to undertake this procedure in order to enable medical staff to ensure I am fit to train and
compete.
• I am aware that some information may require clarification or follow-up with my treating doctor and
physio/athletic therapists, and agree to the release of relevant information to these people.
• I am aware that medical fitness issues may be discussed with my coach.
• I understand that the information contained in this form is otherwise confidential and can only be released
with my consent.

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and
true.

b) External Consultation

I understand that if I choose to seek outside medical advice for an injury or medical condition that interferes
with my ability to play, I will have to be re-evaluated by a McGill Sport Medicine Clinic doctor before being
cleared to return-to-play.

Also, I understand that in order to facilitate this re-evaluation process, it is my responsibility to provide the
McGill Sport Medicine Clinic doctor the test results, reports and/or images from the external sources.

If there is a discrepancy of opinion concerning return-to-play between an outside physician and a McGill Sport
Medicine Clinic doctor, I understand that the McGill Sport Medicine Clinic doctor’s opinion will prevail.

_____________ _________________________ _____________________________

Date Print name Signature

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For Football, Hockey and Soccer only:

Head circumference : __________ cm

(occiput to frontal area: largest circumference found)

Neck circumference: __________ cm

(measured at Adams’ apple)

Doctor’s Notes ...........................................................................................................................................

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Doctor’s signature___________________________________________ Date_____________

NAME: ___________________________

SPORT: ___________________________

DOCTOR: Dr. Eileen Bridges ρ

Dr. Scott Delaney ρ

Dr. Vincent Lacroix ρ

Dr. Fany Fallenbaum ρ

Dr. Kathryn Sun ρ

Dr. Penny Baylis ρ

Dr. Monica Cermignani ρ