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    Soccer Player Medical History Form Template

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    josephkwasikumah16
    This medical history form collects important health information about an athlete. It requests their name, address, date of birth, height, weight and blood type. It also asks for provincial medical and insurance numbers. Emergency contact details are collected along with the athlete's family physician's contact information. The form then outlines common health conditions and injuries, asking the athlete to indicate if they have experienced any in the past or present. Space is provided to explain any conditions marked "yes" as well as to list any current prescribed or non-prescribed medications. The completed form is signed and dated.

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    Soccer Player Medical History Form Template

    Uploaded by

    josephkwasikumah16
    12 views1 page
    This medical history form collects important health information about an athlete. It requests their name, address, date of birth, height, weight and blood type. It also asks for provincial medical and insurance numbers. Emergency contact details are collected along with the athlete's family physician's contact information. The form then outlines common health conditions and injuries, asking the athlete to indicate if they have experienced any in the past or present. Space is provided to explain any conditions marked "yes" as well as to list any current prescribed or non-prescribed medications. The completed form is signed and dated.

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    This medical history form collects important health information about an athlete. It requests their name, address, date of birth, height, weight and blood type. It also asks for provincial medical and insurance numbers. Emergency contact details are collected along with the athlete's family physician's contact information. The form then outlines common health conditions and injuries, asking the athlete to indicate if they have experienced any in the past or present. Space is provided to explain any conditions marked "yes" as well as to list any current prescribed or non-prescribed medications. The completed form is signed and dated.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    12 views1 page

    Soccer Player Medical History Form Template

    Uploaded by

    josephkwasikumah16
    This medical history form collects important health information about an athlete. It requests their name, address, date of birth, height, weight and blood type. It also asks for provincial medical and insurance numbers. Emergency contact details are collected along with the athlete's family physician's contact information. The form then outlines common health conditions and injuries, asking the athlete to indicate if they have experienced any in the past or present. Space is provided to explain any conditions marked "yes" as well as to list any current prescribed or non-prescribed medications. The completed form is signed and dated.

    Copyright:

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    MEDICAL HISTORY FORM

    ATHLETE’S SURNAME: ATHLETE’S GIVEN NAME:

    ADDRESS: DATE OF BIRTH (M/D/Y):

    HEIGHT: WEIGHT:

    BLOOD GROUP & TYPE:

    PROVINCIAL MEDICAL NO: MEDICAL INSURANCE NO:

    FAMILY PHYSICIAN: PHONE:

    NEXT OF KIN: PHONE:

    IN CASE OF EMERGENCY
    PLEASE NOTIFY: PHONE:

    OUTLINE PAST HISTORY OR ILLNESS


    HAVE YOU EVER HAD OR DO YOU NOW HAVE:
    YES NO YES NO
    HEAD INJURY ___ ___ DIABETES ___ ___
    SEIZURES ___ ___ BLOOD TRANSFUSIONS ___ ___
    NECK/BACK DISRODER ___ ___ HEPATITS ___ ___
    FAINTING SPELLS ___ ___ THYROID DISORDER ___ ___
    PSYCHIATRIC DISORDER ___ ___
    EYE PROBLEMS ___ ___ ALLERGIES ___ ___
    GLASSES/CONTACTS ___ ___ (SPECIFY)
    NOSE BLEEDS ___ ___
    DENTAL PROBLEMS ___ ___ FRACTURES ___ ___
    DEAFNESS/EARPROBLEMS ___ ___ (SPECIFY)
    ASTHMA ___ ___
    BRONCHITIS ___ ___ OPERATIONS ___ ___
    CHEST PAINS ___ ___ (SPECIFY)
    HEART PROBLEMS ___ ___
    ULCERS ___ ___ RECENT WITHIN ONE YEAR:
    BOWEL PROBLEMS ___ ___ INFECTIOUS DISEASE ___ ___
    URINARY INFECTIONS ___ ___ HEAD INJURY ___ ___
    KIDNEY PROBLEMS ___ ___ MAJOR SURGERY ___ ___
    MENSTRUAL PROBLEMS ___ ___ TRAUMATIC OR
    EATING DISORDERS ___ ___ OVERUSE INJURY ___ ___

    *PLEASE LIST ANY OTHER HEALTH PROBLEMS OR RELEVANT INFORMATION OR EXPLAIN ANY OF THE CONDITIONS MAKED
    “YES”:

    MEDICATIONS CURRENTLY USED


    DATE COMPLETED: _______ ________________________________
    PRESCRIBED:

    NON PRESCRIBED: SIGNATURE OF PARENT/GUARDIAN ________________

    BC Soccer Development Department

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