ATHLETE’S MEDICAL HISTORY REPORT
Name: _____________________________________________________________________________________________________________________
Last First Middle
Date of Birth ____________________ Sex _________
Address ______________________________________________________________________
Emergency Contact _____________________________ Phone (____) _______________________
Please circle “YES” or “NO” and provide additional details where requested on all three sides of this form.
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
NO YES ( list and give reason) ____________________________________.
2. Do you take any prescribed medication on a permanent or semi-permanent basis
(Steroids, anti-inflammatory, antibiotics, insulin, etc.)?
NO YES (list and give reason) ____________________________________.
3. Have you ever had an epileptic seizure?
NO YES
4. Have you ever been told by a doctor that you have epilepsy?
NO YES (list any medication) ___________________________________.
5. Have you ever been treated for diabetes?
NO YES (list any medication) ____________________________________.
6. Have you ever been told by a doctor that you were anemic?
NO YES When? _______________ What treatment? _________________.
7. Have you ever been told by a doctor that you have sickle cell anemia?
NO YES
8. Do you have or have you ever had high blood pressure?
NO YES (list any medication) ___________________________________
9. Do you have, or have you ever had, the following diseases?
Heart disease (heart murmur, rheumatic fever, other)
NO YES (give name and date) ____________________________________
10. Lung disease (pneumonia, other)
NO YES (give name and date) ____________________________________
11. Liver disease (mononucleosis, hepatitis, other)
NO YES (give name and date) ____________________________________
12. Have you ever been told by a doctor that you have asthma?
NO YES (list any medication) ____________________________________
13. Do you have or have you ever had a hernia or “rupture”?
NO YES (if so, has it been repaired?) ________________________________
14. Have you been “knocked out” or become unconscious in the past three years?
NO YES (if so, describe and give date(s) ____________________________
15. Have you had a concussion or other head injury in the past three years?
NO YES (if so, describe and give dates ____________________________
16. Have you stayed overnight in a hospital due to a head injury?
NO YES (if so, list dates) ________________________________________
17. Have you ever had a neck injury involving bones, nerves, or disks that disabled you?
for a week or longer?
NO YES Type of injury _____________________ Date(s) _____________
18. Do you wear glasses or contacts during competition?
NO YES
19. Do you wear any of the following dental appliances?
NO YES (Circle those that apply)
Permanent bridge Braces Removable retainer Permanent retainer
Removable partial plate Full plate Permanent crown or jacket
20. Have you had a broken bone (fracture) in the past two years?
NO YES
What bone? _______________________ right or left? ________ Date __________
21. Have you had a shoulder injury in the past two years that disabled you for a week or
longer (dislocation, separation, etc.)?
NO YES
Type of injury ___________________ right or left? _______ Date(s) ____________
22. Have you ever had shoulder surgery?
NO YES What was done and why? ________________________________
Right or left? ____________________ Dates_________________________
23. Have you ever injured your back?
NO YES
Type of injury ________________________ Dates ________________________
24. Do you have back pain?
NO YES (Circle any that apply)
Seldom Occasionally Frequently With vigorous exercise With heavy lifting
25. Have you injured your knee in the past two years?
NO YES
26. Have you been told by a doctor or athletic trainer that you injured the cartilage in
your knee?
NO YES right or left? ______________________ Dates _______________
27. Have you ever had knee surgery?
NO YES What was done and why? ________________________________
28. Have you had a severe ankle sprain in the past two years?
NO YES
29. Do you have a pin, screw, or plate in your body?
NO YES
Where in your body? ___________________ Date(s) _________________
30. Do you have any other conditions that we should be aware of (i.e., ulcers, food or
insect allergies, tendonitis, etc.)?
NO YES (specify and give details) _____________________________________________________________________________________________________
31. Please give the dates of your last tetanus and polio shots:
Tetanus: ________________ Polio: __________________
The questions on all three pages of this form have been answered completely and truthfully to the best of my knowledge.
Sign X _________________________________________________________ Date ________________________