NDHSAA 2020-21 ANNUAL SPORTS HEALTH QUESTIONNAIRE – FORM B
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Check Yes or No boxes for each question or Circle question numbers for which you cannot answer.
IN THE LAST YEAR, since your last complete Sports Qualifying Exam with your physician, HAVE YOU HAD ANY CHANGES TO THE FOLLOWING QUESTIONS:
Athlete Health Questionnaire
Over the past 2 weeks, how often have you been bothered by any of the following problems? (Circle response.)
Not at all Several days Over half the days Nearly every day
Feeling nervous, anxious, or on edge 0 1 2 3
Not being able to stop or control worrying 0 1 2 3
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
(If the sum of responses to questions 1 & 2 or 3 & 4 are ≥3, please see your provider) YES NO
IMPORTANT HEART HEALTH QUESTIONS ABOUT YOU IN THE LAST YEAR
IMPORTANT HEART HEALTH QUESTIONS ABOUT YOUR FAMILY IN THE LAST YEAR