Download SPORT CLUB MEDICAL HISTORY FORM

Campus Recreation Services
SPORT CLUB MEDICAL HISTORY FORM
NAME: _________________________________________________ DATE: __________________
(Last)
(First)
(MI)
CSU ID: ______________________
CLUB: ___________________________
ADDRESS: ________________________________________________
DATE OF BIRTH: ________________________
PHONE: _________________________
AGE: _____________
EMERGENCY CONTACT: ________________________________
GENDER: ____________
RELATIONSHIP: ______________________
PHONE: __________________________
Have you ever been restricted from athletic/recreational participation due to health problems?
 If yes, please list reason and date: _______________________________________________
Yes
No
Do you have any known allergies?
 If so, list: __________________________________________________________________
Yes
No
Are you currently taking any medications?
 If so, list: __________________________________________________________________
Yes
No
Do you currently have a muscle, joint or back disorder that could be aggravated by physical activity?
Yes
No
Do you have an ongoing medical condition such as diabetes or asthma?
 If so, list: __________________________________________________________________
Yes
No
Do you currently wear glasses or corrective lenses?
Yes
No
Have you ever had a head injury or concussion?
 If so, when was your last one? __________________________________________________
 If so, how many have you had? __________________________________________________
 If so, do you have any current problems? __________________________________________
Yes
No
Have you ever had a stress fracture?
Yes
No
Do you regularly use a brace or an assistive device?
 If so, list: ____________________________________________________________________
Yes
No
List any recent operations, serious illness or hospitalizations and the dates of each: _______________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I certify that the medical history above is accurate and complete to the best of my knowledge.
SIGNATURE: ____________________________
DATE: __________________