Sports Physical Health Risk Assessment Form
Full Name
Date of Birth
Sport
Emergency Contact Name & Phone
Medical History
Have you ever been diagnosed with any of the following?
Asthma
Diabetes
Epilepsy/Seizures
Heart Disease
None
Other medical conditions (if any)
Are you currently taking any medications?
Yes
No
If yes, please list them
Do you have any allergies?
Yes
No
If yes, please specify
Family History
Any family history of medical conditions? (e.g. heart disease, sudden death under age 50)
Physical Symptoms
Have you experienced any of the following?
Fainting during exercise
Chest pain/tightness
Unexplained dizziness
Shortness of breath
None
Past injuries or surgeries (including dates)
Other concerns or relevant information