Athlete'S Medical History Form
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1MEDICAL HISTORY FORM
ATHLETE’S SURNAME:
ATHLETE’S GIVEN NAME:
ADDRESS:
DATE OF BIRTH (M/D/Y):
HEIGHT:
WEIGHT:
BLOOD GROUP & TYPE:
PROVINCIAL MEDICAL NO:
MEDICAL INSURANCE NO:
FAMILY PHYSICIAN:
PHONE:
NEXT OF KIN:
PHONE:
IN CASE OF EMERGENCY
PLEASE NOTIFY:
PHONE:
OUTLINE PAST HISTORY OR ILLNESS
HAVE YOU EVER HAD OR DO YOU NOW HAVE:
YES
NO
YES
NO
HEAD INJURY
___
___
DIABETES
___
___
SEIZURES
___
___
BLOOD TRANSFUSIONS
___
___
NECK/BACK DISRODER
___
___
HEPATITS
___
___
FAINTING SPELLS
___
___
THYROID DISORDER
___
___
PSYCHIATRIC DISORDER
___
___
EYE PROBLEMS
___
___
ALLERGIES
___
___
GLASSES/CONTACTS
___
___
(SPECIFY)
NOSE BLEEDS
___
___
DENTAL PROBLEMS
___
___
FRACTURES
___
___
DEAFNESS/EARPROBLEMS
___
___
(SPECIFY)
ASTHMA
___
___
BRONCHITIS
___
___
OPERATIONS
___
___
CHEST PAINS
___
___
(SPECIFY)
HEART PROBLEMS
___
___
ULCERS
___
___
RECENT WITHIN ONE YEAR:
BOWEL PROBLEMS
___
___
INFECTIOUS DISEASE
___
___
URINARY INFECTIONS
___
___
HEAD INJURY
___
___
KIDNEY PROBLEMS
___
___
MAJOR SURGERY
___
___
MENSTRUAL PROBLEMS
___
___
TRAUMATIC OR
EATING DISORDERS
___
___
OVERUSE INJURY
___
___
*PLEASE LIST ANY OTHER HEALTH PROBLEMS OR RELEVANT INFORMATION OR EXPLAIN ANY OF THE CONDITIONS MAKED
“YES”:
MEDICATIONS CURRENTLY USED
DATE COMPLETED: _______
________________________________
PRESCRIBED:
NON PRESCRIBED:
SIGNATURE OF PARENT/GUARDIAN
________________
BC Soccer Development Department
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Parent category: Medical