Disabled Athlete Adaptive Sports Medical History
Personal Information
Name
Date of Birth
Gender
Male
Female
Non-binary
Prefer not to say
Other
Contact Information
Phone
Email
Address
Disability & Medical History
Primary Diagnosis
Year of Onset/Injury
Type of Impairment
Amputation
Cerebral Palsy
Spinal Cord Injury
Visual Impairment
Intellectual Impairment
Other
Assistive Devices Used
Current Medications
Allergies
Sports Participation
Adaptive Sports Interested In
Experience in Sports
Additional Medical Information
Past Surgeries
Special Considerations
Notes