UNIVERSITY FOOTBALL
MEDICAL FORM
SKILLS-4-KIDS
Player’s Name: ________________________________ Date of birth (dd/mm/yy): _________________
ID Number: __________________________________
Personal History Questionnaire
Have you ever fainted or passed out when exercising?
Y
N
Do you ever have chest tightness?
Y
N
Does running ever cause chest tightness?
Y
N
Have you ever had chest tightness, cough, wheezing which made it difficult for you to perform in sport?
Y
N
Have you ever been treated/hospitalized for asthma?
Y
N
Have you ever had a seizure?
Y
N
Have you ever been told that you have epilepsy?
Y
N
Have you ever been told to give up sports because of health problems?
Y
N
Have you ever been told you have high blood pressure?
Y
N
Have you ever been told you have high cholesterol?
Y
N
Do you have trouble breathing or do you cough during/after exercise?
Y
N
Have you ever been dizzy during/after/exercise?
Y
N
Have you ever had chest pain during/after exercise?
Y
N
Do you have/Have you ever had racing of your heart or skipped heartbeats?
Y
N
Do you get tired more quickly than your friends do during exercise?
Y
N
Have you ever been told you have a heart murmur?
Y
N
Have you ever been told you have a heart arrhythmia?
Y
N
Do you have any other history of heart problems?
Y
N
Have you had a severe viral infection(e.g. myocarditis or mononucleosis) within the last month?
Y
N
Have you ever been told you had rheumatic fever?
Y
N
Do you have any allergies?
Y
N
Are you taking any medications at the present time?
Y
N
Have you routinely taken any medication in the past two years?
Y
N
Family History Questionnaire
Has anyone in your family less than 50 years old:

Died suddenly and unexpectedly?
Y
N

Been treated for recurrent fainting?
Y
N

Had unexplained seizure problems?
Y
N

Had unexplained drowning while swimming?
Y
N

Had unexplained car accident?
Y
N

Had heart transplant?
Y
N

Had pacemaker or defibrillator implanted?
Y
N

Been treated for irregular heartbeat?
Y
N

Had heart surgery?
Y
N
Has anyone in your family experienced sudden infant death?
Y
N
Has anyone in your family been told they have Marfan syndrome?
Y
N
Physical Examination (to be completed by examining physician)
General:
Findings
Radial and Femoral Pulses
Marfan Stigmata
Cardiac Auscultation:
Rate
/min
Rhythm
Murmur: Systolic/Diastolic
Systolic Click
Blood Pressure
mmHg
Height
cm
Weight
kg
Body Mass Index
kg/m2
Cases with positive personal history, family history of potentially inherited disease,
positive physical findings or other medical issues may require further assessment or
evaluation by a specialist to qualify the athlete for sport participation.
Is this required? (If yes, please include additional comment in the space below).
Y
N
To be completed by a medical doctor:
I have medically examined the child named above and certify that in my professional opinion he/she is fit to
participate in football training and competitions.
Doctor’s Name: ______________________________________ Date: ________________________
Official Stamp: _____________________________ Signature: ____________________________
I, the undersigned, as legal guardian of the above minor, give University Football Skills-4-Kids my unconditional consent to
store the above information and share it with any personnel for football, medical or any other legitimate purposes. University
Football Skills-4-Kids may continue to keep this information until I otherwise request in writing. I confirm that I will inform the
club of any changes to these details. I am aware that some information may require clarification or follow-up with my treating
physician and possibly other specialists, and agree to the release of relevant information to these people.
Should I not accompany my child to University Football Skills-4-Kids events I agree to remain contactable and I understand that
if my child should require emergency treatment University Football Skills-4-Kids will make every effort to contact me on the
contact details provided on the Application Form. If however I am not contactable on the numbers/contact details provided I
authorise University Football Skills-4-Kids to consent on my behalf for an anaesthetic to be administered, or any other urgent
medical treatment to be given to my child.
Name: __________________________________________________________________________
Parent/Legal Guardian (Please Print in Ink)
Signature: _________________________________________
Parent/Legal Guardian
Date: ______/______/______
NOTE: It is important that you ensure that your child has the relevant medication they may need with them when
attending matches or training, clearly labelled with their name.
MALTA UNIVERSITY SPORTS AND LEISURE
T: +356 2340 8907/ 9942 0026
E: info@universitysportsandleisure.com
www.universitysportsandleisure.com