Sports Physical Medical History Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Emergency Contact
Name
Phone Number
Relationship
Medical History
Have you ever had (check all that apply):
Asthma
Diabetes
Seizures
Heart Problems
Other
If yes to any above, explain:
Allergies
List any allergies:
Current Medications
List any medications you are currently taking:
Past Injuries or Surgeries
List any past injuries or surgeries:
Additional Information
Other important information: