Wrestling Medical History Form
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Medical History
Today’s Date_______
Name__________________________________ Birth Date________ Age________
Last
First
Int
Parent or Guardian ________________________________
Phone_______________________
Home Address_________________________________________________________________________
Street & Number
City
St
Zip
Phone Number _________________
Alt Phone___________________
Emergency Contact__________________________________________________
Home Address__________________________________________________________________________
Street & Number
City
St
Zip
Phone Number__________________
Alt Phone________________
Health History (check-giving approximate date)
Diseases
Frequent Ear Infections
________
Psychiatric Treatment
______
Chicken Pox
_____
Heart Defect/Disease
________
Mononucleosis
______
Measles
_____
Convulsions
________
Asthma
______
German Measles _____
Diabetes
________
Mumps
_____
Bleeding/Clotting Disorders ________
Hypertension
________
Has this camper ever required any psychiatric counseling or hospitalization? _________________________
Operations or serious injuries (dates):________________________________________________________
Disability or chronic or recurring illness:_____________________________________________________
Any specific activities to be encouraged or limited by physician’s advice :___________________________
_____________________________________________________________________________________
Dietary Modifications: ___________________________________________________________________
Current medication (send w/instructions): ____________________________________________________
Other diseases or details of above: __________________________________________________________
Name of family physician:_______________________________ Phone ____________________
Date of last physical examination: _______________________________
Do you carry family medical/hospital insurance?__________ If so, indicate:_______________________
Carrier_____________________________
Policy of Group No____________________________
Important- Box A or B must be complete to assist your child in case of an emergency
A. Permission to provide necessary treatment of emergency care:
I hereby give permission to the medical personnel selected by the camp director to order X-rays,
routine tests, treatments; to release any records necessary for insurance purposes; and to provide or
arrange necessary related transportation for me/or my child. In the event I cannot be reached in an
emergency, I hereby give permission to the physician selected by the camp director to secure and
administer treatment, including hospitalization, for the person named above. This completed form
may be photocopied for trips out of camp.
Signature of parent or guardian or adult camper/staff__________________________________
B. I do not wish to give the camp permission to give emergency care if I cannot be reached.
Signature________________________________________
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