Norwin Aqua Club Medical History Questionnaire Name_________________________________________________________________________________ Last First Middle Date of Birth __________________________ Sex __________ Address _______________________________________________________________________________ Emergency Contact ____________________________________ Phone (______)____________________ Please circle “YES” of “NO” and provide additional details where requested on this form 1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? NO YES (list) ____________________________________________________________ 2. Do you take any prescribed medication on a permanent or semi-permanent basis (steroids, anti-inflammatory, antibiotics, insulin, 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 any 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 were anemic? NO YES When? _________________ What treatment? ___________________________ 7. Have you ever been told by a doctor that you have sickle cell anemia? NO YES 8. Do you have or have you ever had high blood pressure? NO YES (list any medication) _______________________________________________ 9. Do you have, or have you ever had, the following diseases? Heart disease (heart murmur, rheumatic fever, other) NO YES (give name and date) _______________________________________________ Lung disease (pneumonia, other) NO YES (give name and date) _______________________________________________ Kidney disease (infections, other) NO YES (give name and date) _______________________________________________ Liver disease (mononucleosis, hepatitis, other) NO YES (give name and date) _______________________________________________ 10. Have you ever been told by a doctor that you have asthma? NO YES (list any medication) _______________________________________________ 11. Do you have or have you ever had a hernia or “rupture”? NO YES (if so, has it been repaired?) _________________________________________ 12. Have you been “knocked out” or become unconscious in the past three years? NO YES (if so, describe and give date(s) _______________________________________ 13. Have you had a concussion or other head injury in the past three years? NO YES (if so, describe and give date(s) _______________________________________ 14. Have you stayed overnight in a hospital due to a head injury? NO YES (if so, list date(s) __________________________________________________ 15. Have you ever had a neck injury involving bones, nerves, or disks that disabled you for a week or longer? NO YES Type of injury ___________________________ Date(s) __________________ 16. Do you wear glasses or contacts during competition? NO YES 17. Do you wear any of the following dental appliances: NO YES (Circle those that apply) Permanent bridge Braces Removable retainer Permanent retainer Removable partial plate Full plate Permanent crown or jacket 18. Have you had a broken bone (fracture) in the past two years? NO YES What bone? ___________________________ right or left? _______________ Dates _________ 19. Have you had a shoulder injury in the past two years that disabled you for a week or longer (dislocation, separation, etc.)? NO YES Type of injury _________________________ right or left? _______________ Dates _________ 20. Have you ever had shoulder surgery? NO YES What was done and why? ___________________________________________ Right or left? _____________________ Dates _____________________ 21. Have you ever injured you back? NO YES Type of injury ___________________________________________ Dates (s)_______________ 22. Do you have back pain? NO YES (Circle any that apply) Seldom Occasionally Frequently With Vigorous Exercise With Heavy Lifting 23. Have you injured your knee in the past two years? NO YES 24. Have you been told by a doctor or athletic trainer that you injured the cartilage in your knee? NO YES right or left? ____________________ Date (s) __________________________ 25. Have you ever had knee surgery? NO YES What was done and why? ___________________________________________ Right or left? ______________________ Dates (s) ____________________________________ 26. Have you had a severe ankle sprain in the past two years? NO YES 27. Do you have a pin, screw, or plate in your body? NO YES Where in you body? _____________________________________ Date(s) _________________ 28. Do you have any other conditions that we should be aware of (i.e., ulcers, pregnancy, food or insect allergies, tendonitis, etc.)? NO YES (Specify and give details) ______________________________________________________________________________ ______________________________________________________________________________ 29. Please give the dates of your last tetanus and polio shots: Tetanus: ______________________ Polio: ________________________ The questions on this form have been answered completely and truthfully to the best of my knowledge. ______________________________________________________________ __________________ Signature of Athlete (of parent of athlete is a minor) Date |