Medical Form
Drillers Medical Form 2024
Name (First & Last) *
Home address (include city/postal code) *
Phone # *
Email *
AHC # *
Emergency Contact Name *
Relationship *
Emergency Contact Phone #1 *
Emergency Contact Phone #2
Family History (any member of your immediate family (parents, grand parents, siblings) had the following? *
no
yes
Sudden death before the age of 50?
Heart disease or high blood pressure
Other (eg, diabetes, liver disease)
If you said yes to any of the above, please provide a brief explanation.
Relevant Medical History - Have you had any of the Following conditions? *
no
yes
Heart Murmur
Heart disease/conditions
High blood pressure/cholesterol
Diabetes
Asthma or breathing issues
Epilepsy or Seizures
Heat Exhaustion
Dizziness or faint during exercise
Chest pain with exercise
Kidney problems
Surgery or hospital in last 5 years
Other medical conditions
If you said yes to any of the above, please provide a brief explanation
Previous Injuries (have you had an injury or recurrent pain in any of the following body parts? *
No
Yes
Head
Neck
Back
Shoulder
Elbow/Forearm
Hand/wrist
Knee/Leg
Ankle/foot
Other
If you said yes to any of the above, please provide a brief explanation.
Please list all medications you are currently taking. (include prescribed/ over the counter medications, vitamins, supplements, natural remedies)
Allergies & reactions (including medications/drugs, tape, food, enviromental, etc.)
Have you ever experienced a concussion or head injuries *
If yes, list them all (when, how long were you out and who cleared you?)
Have you ever lost consciousness? *
If yes, When and how long were you out for?
Please list any other medical conditions or health concerns.
By checking the box, I, the undersigned certify that I have made a full and complete disclosure in answering the questions above.  I will advise Drillers Sports staff of any changes pertaining to my personal information and relevant health history.  I consent to the assessments and treatments offered or recommended to me by my health care provider and I intend to this consent to be applied to my present and future care. *
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