Medical Diagnostic Form For Athletes Who Are Participating In Ibsf Para-Sport Events (Page 2 of 4) in pdf

Full name: __________________________________________________________

Date:_______________



No.

Bone, joint, or other deformity

23.

Eye trouble

Stomach, liver, or intestinal trouble

24.

Severe tooth or gum trouble

25.

Ear, nose, or throat trouble

Loss of finger or toe

26.

Gall bladder trouble or gall stones

Jaundice or hepatitis

Chronic or frequent cold

27.

Hearing loss

Recurrent back pain

28.

Broken bones

Rupture or hernia

29.

Hay fever

30.

Sinusitis

Neuritis

31.

Tumor, growth, cyst, or cancer

Frequent or painful urination

10.

Head injury

32.

Skin diseases

11.

Paralysis

33.

Epilepsy

12.

34.

Depression or excessive worry

Kidney stone or blood in urine

13.

35.

Pain or pressure in the chest

Tuberculosis

14.

High or low blood pressure

36.

Frequent trouble sleeping

15.

Scarlet fever

37.

Frequent indigestion

16.

Recent weight gain or loss

38.

Shortness of breath

17.

39.

Heart trouble

Loss of memory or amnesia

18.

40.

Swollen/painful joints

Venereal Disease

19.

Frequent/severe headache

41.

Palpitation or pounding heart

20.

Dizziness or fainting spells

42.

Rheumatic fever

21.

43.

Leg cramps

Arthritis, rheumatism or bursitis

22.

44.

Chronic cough

Adverse reaction to serum drug or

medicine

Explain „” answers:

____________________________________________________________________________

Past surgical procedures (attach additional page if necessary):

1.____________________________________________________Date:__________

2.____________________________________________________Date:__________

3.____________________________________________________Date:__________

Medical Diagnostic Form For Athletes Who Are Participating In Ibsf Para-Sport Events Page 2

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