Medical History Form
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1MEDICAL HISTORY FORM
Name: _______________________________________________________ Date: ____________________
_
Address ______________________________________________________ Birthdate: ________________
__________________________________________________________
Daytime Phone: __________________________________ Evening Phone: ___________________________________
WHO TO CONTACT IN CASE OF EMERGENCY?
Name: ________________________________________________ Relationship: _______________________
Daytime Phone: ________________________________ Evening Phone: ______________________________________
Physician’s Name: _________________________________________________________________________________
Daytime Phone: ________________________________ Evening Phone: _____________________________________
Hospital of Choice: ________________________________________________________________________
PLEASE COMPLETE THE FOLLOWING:
If the answer to any of the following questions is or was yes, please describe the problem and its implications for
proper first aid treatment on a separate piece of paper.
Have you had (or do you presently have) any of the following?
Circle One
Head
injury (concussion, skull fracture)
Yes
No
Fainting spells
Yes
No
Convulsions/epilepsy
Yes
No
Neck or back injury
Yes
No
Asthma
Yes
No
High Blood Pressure
Yes
No
Kidney problems
Yes
No
Hernia
Yes
No
Diabetes
Yes
No
Heart murmur
Yes
No
Allergies
Yes
No
Specify:_____________________________________________________
Injuries to
Shoulder
Yes
No
Knee
Yes
No
Ankle
Yes
No
Fingers
Yes
No
Arm
Yes
No
Other: _______________________________________________________
Impaired vision
Yes
No
Impaired hearing
Yes
No
Other:
Have you had a recent tetanus booster? _______ If so, when? _____________________________________
Are you currently taking any medications? _______ What? Why? ____________________________________
Has the doctor placed any restrictions on your activity? ______ Explain _______________________________
________________________________________________________________________________________
Signed: _______________________________________________________ Date: _____________________
(Athlete)
Signed ________________________________________________________ Date: _____________________
(Parent)
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