MEDICAL HISTORY QUESTIONNAIRE

SWIMMER NAME: ________________________________________________

INSURANCE CO. __________________ POLICY # ______________________

POLICY HOLDER: ________________________________________________

Please circle “YES” or “NO” and provide additional details where requested.

1. Are you allergic to any medication (aspirin, penicillin, etc.?) YES NO

List them: _________________________________________________

2. Do you take any prescribed medication on a permanent or semi-permanent basis (steroids, anti-inflammatories, antibiotics, insulin, etc.) YES NO

List them: _________________________________________________

3. Have you ever had or been told by a doctor that you have had any of the following?

Epileptic seizure YES NO Epilepsy YES NO

Diabetes YES NO Anemia YES NO

Sickle Cell Anemia YES NO High Blood Press. YES NO

List Medication(s): ___________________________________________

4. Do you have, or have you ever had, the following diseases?

Heart disease (heart murmur, rheumatic fever, other) YES NO

Lung disease (pneumonia, other) YES NO

Kidney disease (infections, other) YES NO

Liver disease (mononucleosis, hepatitis, other) YES NO

Asthma YES NO

Hernia or rupture YES NO

Concussion or other head injury in past three years YES NO

Neck injury involving bones, nerves, disks YES NO

Broken bone (fracture) in the past two years YES NO

Shoulder injury in the past two years YES NO

Shoulder surgery YES NO

Back injury YES NO

Frequent Back Pain YES NO

Knee injury in the past two years YES NO

Ligament or cartilage injury YES NO

Knee surgery YES NO

Pins, screws or plates in your body YES NO

Severe ankle sprain in the past two years YES NO

5. Do you have any other conditions that we should be aware of (i.e., ulcers, pregnancy, food or insect allergies, tendonitis, etc. YES NO

6. Please give the dates of your last tetanus shot: _____________________

These questions on this form have been answered completely and truthfully to the best of my knowledge.

_________________________ _______ _________________________

Signature of parent or athlete Date Emergency Contact No.