Medical History

Please circle “Yes” or “No” and explain as necessary:

1) Are you allergic to any medication? No Yes

2) Do you take any prescribed medication on a permanent basis? No Yes

3) Have you been diagnosed with epilepsy or do you suffer from other seizures? No Yes

4) Have you been diagnosed with diabetes? No Yes

5) Have you been diagnosed with asthma? No Yes

6) Do you wear contacts during training? No Yes

7) Are you anemic? NO YES

Do you have sickle cell anemia? NO YES

Have you ever had or do you have high blood pressure? NO YES

Do you have heart disease (heart murmur)? NO YES

Do you have lung diseases? NO YES

Do you have kidney diseases? NO YES

Do you have liver disease? NO YES

Have you ever had a hernia/rupture? NO YES

Have you ever had a concussion or head injury (within past 3 years)? NO YES
Have you ever had a neck injury? NO YES

Have you ever had a knee injury? NO YES

Have you ever had a back injury? NO YES

Do you wear dental braces? NO YES

If you answered “Yes” to any of the above questions, please explain:

8) Do you have any other medical condition that the coaches or an EMT/doctor should be aware of (in treating an emergency)?

I have answered this form completely and truthfully to the best of my knowledge.

Signature of Parent or Guardian