Blazesports Bsa Participant Medical Information Form Page 2
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3History of Seizures: Yes
No
If yes, give date of most recent ______________
Do you have a shunt? Yes
No
Date of original shunt________________
Have you had any shunt revisions? Yes
No
Date of revision _______________
Do you have a history of heart disease, heart problems or high blood pressure?
Yes
No
If yes, please explain
Have you ever had a brain injury or concussion? Yes
No
if yes, please give
the approximate date and describe the incident
Do you have any problems with (mark all that apply):
Overheating
Autonomic Dysreflexia
Pain
If any apply, please describe
Do you have scoliosis? Yes
No
Have you had a back fusion? Yes
No
If yes, what level? _______
Do you currently have any pressure sores? Yes
No
If yes, where are they
and how are you treating them?
535 North McDonough Street | Decatur, Georgia 30030 | 404.270.2000 main | 404.270.2039 fax |
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Parent category: Business