Medical History Questionnaire
 
Name ___________________________________________________________________________________
  Last First Middle
 
Parent/Guardian Name(s)_________________________________________________________________
 
Date of Birth ________________________________________ Sex _____________________________
 
Address ________________________________________________________________________________
 
Phone _________________________________ Work Phone ____________________________________
 
Emergency Contact ___________________________ Phone ____________________________________
 
Please Circle Yes or No and provide additional details where requested.
 
1. Are you allergic to any medication (aspirin, penicillin, etc.)? No Yes
 (List) _____________________________________________________________________________
 
2. Do you take any prescribed medication on a permanent or semi-permanent basis 




 (antibiotics, anti-inflammatory, 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 and 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 have asthma? No Yes
 (list any medication) ______________________________________________________________
 
7. Have you ever had a neck injury involving bones, nerves, or discs that disabled you 




 for a week or longer? No Yes
 (type of injury) ____________________________________ Date _________________________
 
8. Will you wear glasses or contacts during practice or competition? No Yes
 
9. Do you have any other conditions that we should be aware of (heart, lung, kidney, 
 
 liver disease, back, knee, shoulder problems, food or insect allergies, etc.)?




 No Yes
 (explain) __________________________________________________________________________
 
 
The questions on this form have been answered completely and truthfully to the best of 




my knowledge.
 
 
________________________________________________________ ____________________________
Signature of parent/guardian Date