Sherwood Park Kings Athletic Club
Athlete Medical History Form
First Name __________________________
Last Name __________________________
Date of Birth (DD/MM/YYYY)_____________________
Health Care # _________________________ Province ___________
Home Phone # _________________________
Address___________________________________________________________________
Emergency Contact Information
Name _______________________________
Relationship _________________________
Phone # ______________________________ City ________________________________
Family Doctor _________________________ Dr. Phone # __________________________
Medical History – you or anyone in your immediate family
Alcohol habit
YES
NO
Intestinal disorder
Anemia
YES
NO
Jaundice
Appendicitis
YES
NO
Kidney disease
Asthma
YES
NO
Bloody urine
Blood disorder
YES
NO
Malfunctioning organs
Cancer
YES
NO
Missing organs
Cyst, tumor or growth
YES
NO
Memory loss
Calcium deposits
YES
NO
Motion sickness
Chest pain or pressure
YES
NO
Mononucleosis
Childhood disease (measles)
YES
NO
Neurological disorder
Collapsed lung
YES
NO
Pneumonia
Coughed up blood
YES
NO
Recurrent headaches
Diabetes
YES
NO
Recurrent nose bleeds
Dizziness or fainting
YES
NO
Rheumatic fever
Epilepsy
YES
NO
Sexually transmitted disease
Excessive bleeding
YES
NO
Shortness of breath
Gout
YES
NO
Sinusitis
Ear pain
YES
NO
Sickle cell anemia
Hearing problems
YES
NO
Skin rash, infection, hives
Hearing aid
YES
NO
Severe dental or gum issue
Heart disease
YES
NO
Smoking habit
Heart murmur
YES
NO
Stomach ulcer
Irregular heartbeat
YES
NO
Stroke
Heat stroke/exhaustion
YES
NO
Sudden death before 50
Hernia
YES
NO
Surgery/hospitalization
Hepatitis
YES
NO
Tonsillitis
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
High or low blood pressure
High blood cholesterol
YES
YES
NO
NO
YES
YES
NO
NO
Tuberculosis
Vision problem
Medical History: Please provide a brief explanation for any of the above YES answers.
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Allergies: List any allergies you have and describe your reaction.
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Medications: List any prescription or non-prescription medications, vitamins or supplements.
_____________________________________________________________________________________
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Physical Examination: Date of last physical exam by a medical doctor and results/findings.
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Do you wear glasses or contacts for sports?
Wear false teeth, braces, plate or dental appliances?
Have you ever been advised not to participate in sports?
Do you have any surgical pins, screws or plates in your body?
Have you been advised to have surgery but it has not occurred?
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Head Injury History: List any previous head injuries (concussions), date and severity.
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Musculoskeletal Injury History: List any musculoskeletal injuries and if they are still a problem.
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Additional Information: including other medical concerns the trainer should be aware of.
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