Athletic Health Information Report
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2SCHENECTADY COUNTY COMMUNITY COLLEGE
Athletic Health Information Report
Upon completion, this form should be returned promptly to the Athletic Director, Schenectady County
Community College, 78 Washington Avenue, Schenectady, New York 12305.
- - - - - - - - - - - - - - - - - - - - - THIS SIDE TO BE COMPLETED BY APPLICANT - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
NAME
SOCIAL SECURITY NO. _______________________________
LOCAL ADDRESS
DATE OF BIRTH _______________ ___________________
LOCAL PHONE
SPORT _______________________ ____________________
PARENT/GUARDIAN
FAMILY PHYSICIAN ___________________ ____________________
ADDRESS
ADDRESS ___________________________ _____________________
TELEPHONE
TELEPHONE ________________________ _____________________
EMERGENCY NAME & NUMBER ______________________________________________________________________
PERSONAL HISTORY
If you ever had or now have any of the following, check yes or no.
YES
NO
YES
NO
Measles
[ ]
[ ]
Skin Infections
[ ]
[ ]
German Measles
[ ]
[ ]
Neck, head or back injury
[ ]
[ ]
Mumps
[ ]
[ ]
Joint injury or surgery
[ ]
[ ]
Chicken Pox
[ ]
[ ]
Fractured or broken bones
[ ]
[ ]
Scarlet Fever
[ ]
[ ]
Trick or locked knee
[ ]
[ ]
Whooping Cough
[ ]
[ ]
Pain or pressure in chest
[ ]
[ ]
Rheumatic Fever
[ ]
[ ]
Palpitations or pounding in chest
[ ]
[ ]
Frequent Colds
[ ]
[ ]
Any heart problems
[ ]
[ ]
Frequent Sore Throats
[ ]
[ ]
Chronic cough
[ ]
[ ]
Eye Trouble
[ ]
[ ]
Difficulty breathing
[ ]
[ ]
Wear Glasses/Contact Lenses
[ ]
[ ]
Collapsed lung
[ ]
[ ]
Ear Trouble
[ ]
[ ]
Other lung problems
[ ]
[ ]
Bronchitis or Pneumonia
[ ]
[ ]
Blood in urine
[ ]
[ ]
Infectious Hepatitis
[ ]
[ ]
Sugar or albumin in urine
[ ]
[ ]
Infectious Mononucleosis
[ ]
[ ]
Kidney problems
[ ]
[ ]
Tuberculosis or Contact w/Tuberculosis
[ ]
[ ]
Loss or absence of any of the following:
Asthma
[ ]
[ ]
Eye
[ ]
[ ]
Hay Fever
[ ]
[ ]
Lung
[ ]
[ ]
Color Blind
[ ]
[ ]
Kidney
[ ]
[ ]
Epilepsy
[ ]
[ ]
Testicle
[ ]
[ ]
Diabete
[ ]
[ ]
Give details of those checked YES. (If necessary, use additional sheet) ________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Are you under the care of a physician?
Yes [ ]
No [ ]
Have you every been hospitalized?
Yes [ ]
No [ ]
If yes, indicate where and for what reason _________________________________________________________________________
IMPORTANT - DO YOU HAVE ALLERGIES TO DRUGS OR MEDICATIONS?
Yes [ ]
No [ ]
DO YOU HAVE ALLERGIES TO SUBSTANCES OTHER THAN MEDICATION?
Yes [ ]
No [ ]
If yes, note the drug(s), medication(s) or other substances to which you are allergic: ______________________________________
______________________________________________________________________________________________________________
Are you presently taking medications? Yes [ ]
No [ ]
If so, state what medications and for what condition. _______________________________________________________
_____________________________________________________________________________________________________
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