Youth Soccer Player Medical History Form
Player Full Name
Date of Birth
Address
Parent/Guardian Name
Contact Phone Number
Contact Email
Has the player ever had any of the following? (Check all that apply)
Asthma
Diabetes
Allergies
Seizures
Heart Condition
None of the above
Current Medications (Name, dosage, frequency)
Allergies (medication, food, insects, other)
Hospitalizations/Surgeries (Date & reason)
Primary Physician Name
Physician Phone
Emergency Contact (other than parent/guardian)
Emergency Contact Phone
Additional Relevant Information