MEDICAL HISTORY FORM

1. Athlete Name *
2. Address *
3. City, State ZIP *
4. Daytime Phone *
5. Evening Phone *
6. Name of Emergency Contact *
7. Relationship *
8. Daytime Phone *
9. Evening Phone *
10. Physician Name *
11. Physician's Daytime Phone *
12. Physician's Evening Phone *
13. Hospital of Choice *
14. Head Injury *
    Yes
    No
    
15. Fainting Spells *
    Yes
    No
    
16. Convulsions/epilepsy *
    Yes
    No
    
17. Neck or Back injury *
    Yes
    No
    
18. Asthma *
    Yes
    No
    
19. High Blood Pressure *
    Yes
    No
    
20. Kidney Problems *
    Yes
    No
    
21. Hernia *
    Yes
    No
    
22. Diabetes *
    Yes
    No
    
23. Heart Murmur *
    Yes
    No
    
24. Allergies *
    Yes
    No
    
25. Explain Allergies  
26. Shoulder *
    Yes
    No
    
27. Knee *
    Yes
    No
    
28. Ankle *
    Yes
    No
    
29. Fingers *
    Yes
    No
    
30. Arm *
    Yes
    No
    
31. Other  
32. Impaired Vision *
    Yes
    No
    
33. Impaired Hearing *
    Yes
    No
    
34. Other  
35. Have you had a recent tetanus booster? *
    Yes
    No
    
36. If so, When?  
37. Are you currently taking any medications? *
    Yes
    No
    
38. If so, What? Why?  
39. Has the doctor placed any restrictions on your activity? *
    Yes
    No
    
40. If so, Explain:  
41. Name of Person Completing Form *
42. Email Address * (Copy of this form will be sent here.)
43.