Student-Athlete Last Name:  
Student-Athlete First Name:   
Sport or Sports: 

PART I: 

Do you now have or have you had any problems in the past with:

1.   Headaches (needing treatment): Yes   No

2.   Heart:   Yes   No

3.   Breathing (Asthma, etc.):   Yes   No

4.   Abdominal pain:   Yes   No

5.   Dizzy spells:   Yes   No

6.   Black outs:   Yes    No

7.   Eyes (except glasses):   Yes   No

8.   Hearing or ears:    Yes   No

9.   Arthritis:   Yes   No

10.   Joint pain or swelling:   Yes   No

11.   Chronic back pain:   Yes   No

12.   Kidneys:   Yes   No

13.   Bladder:   Yes   No

14.   Diabetes:   Yes   No

15.   High blood pressure:   Yes   No

16.   Cancer:   Yes   No

17.   Operations or surgery:   Yes   No

18.   Varicose veins:   Yes   No

19.   Skin disorders:   Yes   No

20.   Eating disorders:   Yes   No

21.   Anemia:   Yes   No

22.   Disorders of the blood:   Yes   No

23.   Convulsions:  Yes   No

24.   Epilepsy:   Yes   No

25.   Mononucleosis:   Yes   No

26.   Fainting:   Yes   No

27.   Hepatitis:   Yes   No

28.   Muscle cramps:   Yes   No

29.   Loss of organ:   Yes   No

*  if yes to any of the above please list number and explain

PART II:

Have you had a previous injury or surgery on any of the following? 

1.   Head (Concussions, fractures, etc.):   Yes   No

2.   Spine:  Yes   No

3.   Abdomen:   Yes   No

4.   Chest:   Yes   No

5.   Shoulder:   Yes   No

6.   Elbow:   Yes   No

7.   Wrist:   Yes   No

8.   Hand:   Yes   No

9.   Hip:    Yes   No

10.   Thigh:   Yes   No

11.   Knee:   Yes   No

12.   Calf or shin:   Yes   No

13.   Ankle:   Yes   No

14.   Foot:   Yes   No 

* If yes to any of the above, please reference number and briefly explain:

PART III:

1. Do you have or have you been tested for Sickle Cell Trait?   Yes   No   Not tested 

2. Do you or have you ever had a heat related illness (Excessive Cramping, Heat Exhaustion, Heat Stroke)?   Yes   No

3. Are you allergic to any medications?


 

4. Please provide us with any additional information that may effect you during you participation at Wesley College (Family history or any item not mention previously):

 By clicking this box, I verify that all the information listed above is correct.