Chronic Illness Athlete Management History Form
Personal Information
Full Name
Date of Birth
Sport
Team/Club
Chronic Illness Details
Diagnosis
Date Diagnosed
Current Symptoms
Current Medications (name, dose, frequency)
Special Treatments/Protocols
History
Frequency of Flare-Ups/Exacerbations
Recent Hospitalizations/Emergency Visits
Past Surgeries (related to illness)
Impact on Training/Competition
Limitations or Modifications Needed
Previous Missed Training/Events (Describe)
Emergency Management
Action Plan in Case of Illness-Related Emergency
Primary Emergency Contact Name & Relationship
Phone Number
Additional Information