Pre-Screen Questionnaire Pre-Screen Questionnaire Name First Last Date MM slash DD slash YYYY SexMaleFemaileDate of Birth MM slash DD slash YYYY Sports Team/Blub Have you taken a baseline ImPACT test? Yes No Date of Test MM slash DD slash YYYY Have you ever suffered a concussion? Yes No Was the concussion resolved? Yes No Date ImPACT test passed MM slash DD slash YYYY Are you being treated for any current medical conditions? Yes No Please list current medical conditions.Are you taking any medications? Yes No Please list medicationsAre you being treated for any current physical injuries? Yes No Please describe the injury and treatmentWhat other regular physical activities do you participate in: Yoga Pilates Weight Lifting Running Cycling Other Please describePlease list any other pertinant notes to your physical condtion that you feel would be important for the screeners to know about.