TeamPages: Chatham-Kent Wildcats Basketball - Medical History Form

Medical History Form

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Medical History Form

C-K Wildcats Athletes Medical History Form

Name

Name:

Date of Birth

Gender of Team Coaching

MaleFemale

Address:

Street Address:
City: State/Province: Country: Zip/Postal Code:

Family Physician

Physician Phone Number:

Current Medication (prescription or over the counter), please state reason for taking:

Medications Athlete is Allergic to:

Other Allergies and Reactions (food/bee stings/latex, etc.)

Medical History that the Athletic Trainer should be aware of (surgeries, recent or chronic injuries, illnesses, physical limitations, absence of organs)

Does the athlete have a history of concussions? How many? When? How severe?

Has the athlete ever “passed out”, had his/her “bell rung”? Describe

Has the athlete ever experienced seizures of any type? Please describe

Emergency Contact

Name:

Relationship to Athlete

Emergency Contact Phone

Emergency Contact 2

Name:

Relationship to Athlete

Emergency Contact 2 Phone

Medical Treatment Consent

I Recognize that as a result of athletic participation, medical treatment on an. emergency basis may be necessary, and further recognize that school personnel may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to.such emergency care, including hospital care, as may be deemed necessary under the then-exiting circumstances and to assume the expenses of such care.

*Agree to Medical Treatment (Digital Signature)

or cancel

Chatham-Kent Wildcats Basketball

Medical History Form

Medical History Form

Medical Treatment Consent

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