Adaptive Sports Pre-Participation Medical History Form
Participant Information
Full Name
Date of Birth
Gender
Email
Phone
Address
Emergency Contact
Name
Relationship
Phone
Medical History
Primary Disability/Diagnosis
Do you use any assistive devices (e.g., wheelchair, crutches)?
Current Medications
Allergies
Previous Surgeries or Hospitalizations
Medical Conditions
Check if you have a history of any of the following:
Asthma
Seizures
Diabetes
Heart Condition
Hypertension
Bleeding Disorder
Other
If other, please specify
Describe any additional medical concerns relevant to participation in adaptive sports
Functional Assessment
Please describe your mobility and any assistance required
Communication Needs
Other adaptive needs or requirements
Physician Information
Name
Phone
Address