ATHLETE MEDICAL HISTORY QUESTIONNAIRE
Vo2Multisport, L.L.C.
Athlete
Name:__________________________
Date of Birth: ___/___/___
Address:________________________________________________________
City:_____________________________
State:_____
Zip:____________
Phone:_________________________ (Day) ____________________________(Eve)
Personal Physician:
Name:____________________________
Address:________________________________________________________
City:_____________________________
State:_____
Zip:____________
Phone: ___________________________
Emergency Contact:
Name:____________________________
Address:________________________________________________________
City:_____________________________
State:_____
Zip:____________
Phone:_________________________ (Day) ____________________________(Eve)
Medical History
Please list any medications taken on a regular basis (prescription and nonprescription)
Medication
Dose
Allergies
Are you allergic to any medications?
Frequency
Reason
______ NO
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______ YES
If yes, please explain.
Allergic to:
Reaction:
Past and Current Medical History
Please list any current illness, recent injuries, recent surgeries, or past medical
problems or surgery of note.
Date
Injury/Illness/Surgery
Do you have or have you had any of the following?
Heart Disease
Heart Attack
Heart Surgery
Heart Murmur
Hypertension
Thyroid Problems
Asthma
Wheezing
Diabetes
Epilepsy
Anemia
Stress Fracture
Y
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
N
_____
_____
_____
_____
_____
_____
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_____
_____
If female, any chance that you could be pregnant? _____ (Y) _____ (N)
Any special medical needs or information the coach should be aware of?
_____________________________________________________________________
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