Medical History Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

MBS Athletics

Student Name

Grade

Date of Birth

YYYY

Sex

Male

Female

Clear selection

Address

Parent Phone Number

Family Physician

Physician Phone Number

Physician Address

Please place a check mark if your child has experienced any of the following conditions:

Surgery or Hospitalization

Fracture, Sprain, Joint Swelling or Pain

Head Injury or Seizures

Fainting from Heat, Had Heat or Muscle Cramps

Asthma, Cough or Difficulty Breathing After Exercise

Heart Murmur, Skipped Beats, or Racing Heart Rate

High Blood Pressure

Any Family Member with Sudden Death under the Age of 50

Stomach or Intestinal Problems

Skin Problems such as Rash, Itch, Acne, Etc.

Vision Problems, Glasses, Contacts, or Eye Guards

Diabetes, Recurrent Infections

Allergies to Bee Stings, Insect Bites, or Medication

Taking Any Medication

Dental Braces, False Teeth

Wear Contacts/Glasses

Any Prosthesis or Aid Including Pads, Braces, Guards, Hearing Aids

Any Restriction in Any Sport for Any Reason

Medical Problem Since Last Year

If needed, please explain any of the above conditions here:

I certify that the above information is true and correct to the best of my knowledge. (Please sign by typing your full name in the space below)

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy