EmailMeForm
Player Medical History From
Player's name
*
First
Last
Player's Birth Date
*
MM
/
DD
/
YYYY
Player's Age
*
Player's gender at birth
*
Please select
Male
Female
List player's current medical conditions:
Does the player have any physical or mental disabilities that would limit or restrict him/her from playing in a regular game?
Has player had a head injury within the past 6 months?
*
Yes
No
Has player ever had any surgeries?
*
Yes
No
Player's current medications:
Medication or food allergies:
Yes
No
List the allergy
Please list any medications that the player is now taking. Include non-prescription medications, vitamins or supplements:
Name of medications or supplements:
1.
2.
3.
4.
5.
6.
7.
MEDICAL HISTORY
Does player currently have:
Diabetes
Heart murmur
Crohn’s disease
High blood pressure
Pneumonia
Colitis
High cholesterol
Pulmonary embolism
Anemia
Hypothyroidism
Asthma
Jaundice
Goiter
Emphysema
Hepatitis
Cancer
Stroke
Stomach/Peptic ulcer
Leukemia
Epilepsy (seizures
Rheumatic fever
Psoriasis
Cataracts
Tuberculosis
Angina
Kidney disease
HIV/AIDS
Heart problems
Kidney stones
Other...
If other please specify
SYSTEMS REVIEW
In the past month, has the player had any of the following problems?
Nervous System
Headaches
Dizziness
Fainting or loss of consciousness
Numbness or tingling
Muscle/Joints/Bones
Back problems
Joint problems
Muscle weakness
Eyes
Loss of vision
Impared vision
Ears
Hearing problems
Skin
Rash
Heart and Lungs
Chest pain
Heart Palpitations
Shortness of breath
Fainting
Swelling in legs or feet
Excessive Coughing
Psychiatric
Anger issues
Suicidal thoughts / attempts
Hallucinations
Homicidal thoughts / attempts
Other Problems
