Medical Form Template For Mha'S - Ramp Interactive (Page 2 of 2) in pdf

____________________________________________________________________________________________________________

HEAD INJURIES / CONCUSSIONS:

Yes

15. Have you ever had a seizure? .................................................................................................................................. o

16. Have you ever had a head injury? ............................................................................................................................ o

Have you ever had a concussion or been “knocked out”, had your “bell rung”, or been “dinged”? ........................... o

If YES, please list:

Number: ______

Date(s)

Activity at the time

Length of unconsciousness (minutes)

Length of time before full return to

activity

Did you have any persistent problems with:

memory YES NO

dizziness YES NO

headaches YES NO

______________________________________________________________________________________________________ ______

NECK INJURIES / BURNERS / STINGERS:

Yes

17. Have you ever had a neck injury (ie, strain, sprain, fracture, etc.) ............................................................................ o

18. Have you ever had a stinger, burner or pinched nerve? ........................................................................................... o

(a burning or numb feeling in the shoulder or arm after a hit to the head, neck or shoulder - aka. “brachial plexus stretch injury”)

If YES, please list:

Number: ______

Date(s)

Activity at the time

Length of time sensation/strength changes persisted?

____________________________________________________________________________________________________________

19. Check any of the areas that you have INJURED IN THE PAST and explain the injury below:

Hand ___

Elbow ___

Neck ___

Hip ___

Shin/Calf ___

Wrist ___

Arm ___

Chest ___

Thigh ___

Ankle ___

Forearm ___

Shoulder ___

Back ___

Knee ___

Foot ___

Year of injury

Type of Injury

Side (right, left, both)

Is it still a problem? (Yes/No)

______________________________________________________________________________________________________

Yes

20. Do you have any incompletely healed injury?........................................................................................................... o

If yes, which injury?_______________________________________________________________________________________

I hereby certify the above information to be correct.

Athlete Signature

Date

____________________________________________

____________________

Parent/Guardian Signature _______________________________________

Date ____________________