Usa Wrestling Medical Packet (Page 4 of 5) in pdf

Usa Wrestling Medical Packet Page 4

Yes No

14. Do you wear contact lenses during competition?

Yes No

15. Have you had a fracture during the past 2 years? If yes, indicate which bone was broken and

the date if happened

Yes No

16. Have you had a shoulder dislocation, separation or other shoulder injury in the past 2 years

that incapacitated you for a week or longer? If so, give the date of the injury.

Yes No

17. Have you ever had surgery to correct a shoulder condition? If so, give the dates and what was done.

Yes No

18. Have you ever had an injury to your back?

Yes No

19. Do you experience Pain in your back? If yes, indicate frequency:

Seldom

Occasionally

Frequently

With vigorous exercise

With heavy lifting

Yes No

20. Have you injured your knee during the past 2 years with severe swelling as a result?

Yes No

21. Have you ever been told that you injured the ligaments and / or cartilage of either knee?

Yes No

22. Have you ever been advised to have surgery to correct a knee problem?

Yes No

23. If the answer to No. 22 is yes, has the surgery been completed? Date

Yes No

24. Have you experienced a severe sprain of either ankle during the past 2 years?

Yes No

25. Have you had any injury to your foot or toes in the past 2 years. If yes, explain:

Yes No

26. Do you have any chronic conditions that have not been mentioned above? If so, explain:

The questions on both sides of this form have been answered completely and truthfully to the best of my knowledge.

Wrestler's Signature

Date

Parent/ Guardian Signature

Date

Usa Wrestling Medical Packet Page 4