Royals Medical History Form
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1Royals Medical History Form
Name: ______________________________ Date: ______________________ Birth date: ____________________
Address:__________________________________________________________________________________________________
City: ___________________________________________State: _______________________ Zip Code: ___________________
Phone(s): Cell _________________________________________ Home: ________________________________
WHO TO CONTACT IN CASE OF AN EMERGENCY?
Name: ________________________________________________ Phone(s): _________________________________
Relationship: __________________________________________
Physician’s Name: ______________________________________ Phone(s): _________________________________
Hospital of Choice: _____________________________________
Please complete the following: (If the answer to any of the following questions is or was yes, please describe the problem and its
implications for proper first aid treatment on the bottom of this page or attach an explanation.) Have you ever had (or do you
presently have) any of the following?
Circle One
Major injuries to: Circle One
Head injury (concussion, skull fracture) YES
NO
Shoulder
YES
NO
Fainting spells
YES
NO
Knee
YES
NO
Convulsions/Epilepsy
YES
NO
Ankle
YES
NO
Neck or back injury
YES
NO
Fingers
YES
NO
Asthma
YES
NO
Arm (Broken Bones)
YES
NO
High blood pressure
YES
NO
Other: ______________________________
Kidney problems
YES
NO
____________________________________
Hernia
YES
NO
Poor vision
YES
NO
Diabetes
YES
NO
Poor hearing
YES
NO
Heart murmur
YES
NO
Other: _________________________________
Allergies
YES
NO
_______________________________________
Specify: _______________________________________
Have you had a recent tetanus booster? If so, when? _______________________________________________
Are you currently taking any medication? What? Why? ____________________________________________
Has the doctor placed any restrictions on your activity? Explain ______________________________________
Signed: _________________________________________________ Date:___ ________________________
(Athlete)
Signed: _________________________________________________ Date: ___________________________
(Parent)
CONSENT TO TREAT
This is to certify that on this date, I, _______________________________________as parent or guardian of
_______________________________________, give my consent to the Polar Summer Hockey staff to obtain medical care
from any licensed physician, hospital or clinic, for the above mentioned athlete, for any injury that could arise from
participation in program activities.
If said athlete, is covered by any insurance company, please complete the following:
Name of Carrier_____________________________ Address ________________________________________
Policy Number ______________________________ Group Number __________________________________
Signed _____________________________________ Relationship to Athlete ___________________________
Home Address _____________________________________________________________________________
Phone ______________________ Date_____________________
Additional information (please write in space provided or on back of sheet.)
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Parent category: Medical