Amateur Baseball Player Pre-Participation Medical Questionnaire
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Emergency Contact Name
Emergency Contact Phone
Medical History
Asthma
Heart Condition
Diabetes
Allergies
History of Concussions
Seizures/Epilepsy
Other (please specify below)
If 'Other', please provide details
Surgical History
Have you had any surgeries or hospitalizations?
Medications
List any current medications
Allergies
List all allergies (including medications, foods, etc.)
Injuries
Do you have any current or previous injuries?
Family History
Family history of sudden cardiac death or heart conditions? If yes, please specify relationship and condition.
Consent
Signature
Date