Returning Athlete Medical History Form - Western Kentucky University
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12016-2017
WESTERN KENTUCKY UNIVERSITY
RETURNING ATHLETE MEDICAL HISTORY FORM
NAME:
DATE:
Last
Middle
First
Sport:
Height:________in.
Weight:_______lbs.
Athlete's Local Address:
Cell Phone #:
Marital
Soc. Sec. #:
Birth Date:
WKU ID:
Single
Status:
Married
No Dashes
MM/DD/YY
Mother / Guardian Contact Information
Father / Guardian Contact Information
Name:
Name:
Address:
Address:
City:
State:
Zip:
City:
State:
Zip:
E-Mail Address:
E-Mail Address:
Phone (H):
Phone (H):
Phone (C):
Phone (C):
Primary Mailing Address
Primary Mailing Address
Instructions: Select yes or no for each question. When the answer is yes, please give details and dates.
YES
NO
1. Have you been hospitalized or had a major illness in the last year?
YES
NO
2. Are you currently ill in any way?
YES
NO
3. Have you had a head injury or been unconscious in the past year?
YES
NO
4. Have you had any other major injury in the past year?
YES
NO
5. Do you have any injury that is not healed at this time?
6. Are you taking any medication at this time? (i.e. Rx for ADHD)
YES
NO
YES
NO
7. If in a fall sport, have you been working out in the hot times of the day during the summer?
YES
NO
8. Do you know of any health reason why you should not participate in athletics at WKU?
YES
NO
9. Do you have an inhaler?
YES
NO
10. Do you have any medication allergy?
YES
NO
11. Do you have any concerns you would like to discuss with a doctor?
I acknowledge and accept the possible risks of serious injury that can occur to me by participation in athletics.
SIGNATURE_______________________________________
DATE_________________
Print Form
Rev. 6-8-14
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