Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
/D
(Date of birth)
/M
/Y
AGE
(City)
(Province)
EMERGENCY CONTACT
(Surname) (First name) (Phone #)
(City)
(Province)
HEALTH QUESTIONNAIRE 1. Have you ever been hospitalized? ..................................................................................................... 2. Are you presently taking any medication or pills? .. 3. Have you ever passed out during or after exercise? ......................................................................... 4. Have you ever been dizzy during or after exercise? ...................................................................... 5. Have you ever had chest pain during or after exercise? ................................................................... 6. Do you have trouble breathing or do you cough during or after activity? .......................................... 7. Do you use any special equipment (pads, scrum cap, brace, eye guard etc.)................................... 8. Have you had any problem with your eyes or vision? ....................................................................... 9. Do you wear glasses or contacts or protective eye wear? ................................................................ 10. Do you have problems hearing or use a hearing device? ............................................................... 11. Do you have asthma? ..................................................................................................................... 12. Do you have a heart condition? ...................................................................................................... 13. Do you have Diabetes? Type 1_
For what purpose?
YES
NO
Type 2_
14. Do you wear a medical information bracelet or necklace? ........... If YES to any of the above please provide further explanation
HISTORY
Please list any medical problems or injuries that you have had in the last two (2) years including tests, xrays, medications or treatment received. If you are still experiencing these problems please list the status as ongoing and if the problem has been resolved, please list the status as resolved. Date Problem or Injury Treatment Current Status
Have you had any surgery? Please describe: Do you have any upcoming medical test or doctors appointments? Please describe: If you are currently receiving any rehabilitation treatment please specify below: Are you currently wearing any type of adaptive equipment in partial treatment or protection for any existing injury or condition (eg orthotics, brace, helmet, etc.)? Please describe:
Name of provider
ALLERGIES
Medication : Food : The environment :
COMMENTS: Head Injuries/Concussions: 1. Have you ever had a head injury? . 2. Have you ever had a concussion or been knocked out, bell rung or been dinged? ....................... If yes please list: Number
Date(s) Activity at the time Length of unconsciousness Length of time before full return to activity
Yes
No