EXAMINATION TO ASSESS FITNESS TO PERFORM SPORTS

Dipartimento di Prevenzione
U.O.C. Medicina dello Sport e dell’Esercizio Fisico
EXAMINATION TO ASSESS FITNESS TO PERFORM SPORTS
Medical History Card for the examination subsequent to the first Medical
Accertamento di idoneità specifica allo sport
Scheda anamnestica per la visita successiva alla prima
Surname ____________________________
Name _______________________________
born in _________________________________________ on _________________________
residence ___________________________________________________________________
identity doc.___________________________ Fiscal Code ____________________________
tel._____________________________ cell. _______________________________________
Sport for which the examination is requested ______________ years of sports activities ____
Sports club to which you belong _________________________________________________
Do you regularly do other sports? YES
Do you train regularly?
YES
NO
NO
Which ones? _________________________
How many hours a week? _____________________
Information concerning the period from the last medical-sports examination in this
structure up to the present date
SICKNESS IN THE FAMILY
YES
NO
which?_______________________________________________________________
SICKNESS OF THE ATHLETE
YES
NO
which?_______________________________________________________________
when? _______________________________________________________________
for how long did you suspend sports activities? _______________________________
ACCIDENTS
YES
NO
which?_______________________________________________________________
when? _______________________________________________________________
for how long did you suspend sports activities? _______________________________
SURGERY
YES
NO
which?_______________________________________________________________
when? _______________________________________________________________
for how long did you suspend sports activities? _______________________________
CURRENT MEDICAL TREATMENT?
YES
NO
which?_______________________________________________________________
for what reason?_______________________________________________________
Specialised examinations undertaken
___________________________________________________________________________
___________________________________________________________________________
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Dipartimento di Prevenzione
U.O.C. Medicina dello Sport e dell’Esercizio Fisico
Other particular information
___________________________________________________________________________
___________________________________________________________________________
Since your last examination in this structure, have you been examined in any other structure
in order to assess your fitness to do competitive sports?
You were declared: FIT
YES
NO
when ______________
NOT FIT: for which reasons ____________________________
SUSPENDED: for how long_______ for which reasons ________________________________
Medical Heart History
Have you ever fainted while at rest, or during or immediately after physical effort?
YES
NO
Have you ever felt that your heart has missed a beat?
YES
NO
When you make physical effort (running, steps):
do you feel or have you felt out of breath?
a sense of constriction like a bar in the middle of your chest?
YES
YES
NO
NO
Have you ever had episodes of a sudden quickening of your heartbeat
with a just-as-sudden return to normality?
YES
NO
YES
YES
NO
NO
Have you ever been suspended from competitive sports activities during
previous examinations for heart reasons?
Have you ever undergone other heart assessments?
Which ones? ___________________________________________________________
Memo for the athlete and Informed Consent for the assessments
This questionnaire is strictly personal and must be completed by the athlete if of age, or by a parent if
underage. The YES NO choice box must always be ticked.
The athlete must always come to the examination with: identity document, any health documentation
(blood tests, hospital discharge letter, results of specialised tests, etc.), health card.
It is advisable not to smoke, drink alcohol or eat abundantly before the test; it is also good conduct to
arrive in a good state of personal hygiene.
Having been informed as to the testing procedures, I hereby consent to undergo the assessment as
provided for by DPR 18.02.1982, in order to receive the Certificate of Fitness to Perform Competitive
Sports.
The undersigned (or parent if the athlete is under the age of 18) declares under their own responsibility
that the information provided in this questionnaire is complete and true.
Do you delegate a member of the club to collect a copy of the certificate?
Date ____________
YES
NO
Signature ___________________________________
of the athlete if of age or of a parent if under-age
The data above will be treated in pursuance of the provisions established by Legislative Decree 196/03 for the
protection of personal data.
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