Fill and Sign the General Pre Participation Form for Student Athlete Nutritional Health Questionnaire

General Pre-Participation Form (Student-Athlete Nutritional Health Questionnaire) Stress fracture History 1. Have you ever had a stress fracture or a stress reaction" Yes____ No____ 2. Have you ever had x-rays to rule out a stress fracture or a Yes____ No____ stress reaction'? 3. Have you ever had a bone scan or bone density test? Yes____ No____ 4. Do you take calcium Yes____ No____ 5. Are you a vegetarian? Yes____ No____ Eating/Weight History 1. What is your highest and lowest weight in the last year?  Highest Weight ___________  Lowest Weight ___________ 2. Have you had any recent changes in weight? Yes____ No____ 3. What is your desired weight? _______ pounds 4. Do you weigh yourself often? Yes____ No____ 5. Do you consciously watch your weight? Yes____ No____ 6. Would your weight be different if you were not exercising vigorously? Yes____ No____ 7. How many times a year do you lose weight intentionally? ____ times 8. When your season is over and you stop or reduce training, do you gain or lose weight? Gain______ Lose_____  If gain how much weight? _______ pounds  If lose, how much weight? _______ pounds  What is your weight In season at the peak of training? _______ pounds 9. Do you have to restrict your food Intake more or less than in the past to be at your competitive weight? Much Less _____Somewhat Less ____No Change _____Somewhat More _____Much More ______ 9. Are you preoccupied with weight? Yes____ No____ 10. Does worrying about weight take up a significant amount of your time? Yes____ No____Menstrual History (Females Only) 1. At what age did you have your first period? Month______ Year______ 2, When was your last period? Month______ Year______ 3. How many periods have you had in the last 12 months? _________ 4. Are you on any form of estrogen/birth control? Yes____ No____ If yes, what form?________________________________________________ How long? ________________________________________________ Why? (control of period, medical prescription, other) ___________________________ If it has been recommended and you are not taking it, why? ___________________________________________________________________________ 5. Have you ever been diagnosed with anemia? Yes____ No____ 6. Do you cat red meat? Yes____ No____ 7. Do you have a heavy menses? Yes____ No____ 8. Were you aware of any effect of regular training for sport on the occurrence of your first menstrual period? Yes____ No____ If yes, briefly explain _______________________________________________ ________________________________________________________________ 9. Are menstrual problems such as cramps and irregularity Yes____ No____ common in your family?