Sport(s):

Basketball Cross Country Football Hockey Soccer Track & Field Volleyball

Sex:

Male Female

Date of Birth:

- month - January February March April May June July August September October November December / - day - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / - year - 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978

Street:			City:
Province / State:			Postal / Zip Code:
Home Phone:		( )

Street:			City:
Province:			Postal Code:
Winsdor Phone:		( )	E-mail:

Health Card No.:
			Version code	Province of Registration

Plan Number:

Insurer:

Name:			Relationship:
Street:			City:
Province:			Postal Code:
Phone:		( )	E-mail:

		Details if “Yes”: dates, severity, medical tests, etc.
Your eyes/vision?	Yes No
Your nose/throat?	Yes No
Your hearing?	Yes No
Headaches, dizziness, fainting?	Yes No
Your co-ordination/balance; or have any problems with weakness?	Yes No
Numbness with any part of your body?	Yes No
Any tendency to shake or tremble?	Yes No
Breathing issues? Yes No	cough shortness of breath chest pain palpitations
Stomach issues? Yes No	poor appetite vomiting abdominal pain abnormal bowel habits
Symptoms related to the muscles / bones / joints? Yes No	stiffness swelling pain
Problems with skin? Yes No	sores rashes itchy burning other
Other symptoms? Specify the details.	Yes No

2. For Female Athletes - Menstrual and Gynaecologic History:

		Details if “Yes”: dates, severity, medical tests, etc.
Do you have pains/cramps during your periods?	Yes No
Any menstrual abnormalities? eg: abnormal bleeding	Yes No
Are you on Birth control pills?	Yes No
Any lumps in your breasts?	Yes No
Other gynaecological problems?	Yes No
Have you had a pap test?	Yes No	Date: - month - January February March April May June July August September October November December / - day - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / - year - 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

3. Drug, food supplement & miscellaneous agents:

		Details if “Yes”: dates, severity, medical tests, etc.
Are you taking any medications at present?	Yes No
Are you taking any vitamin at present?	Yes No
Are you taking any stimulants? (amphetamines, caffeine tablets, etc)	Yes No
Are you taking any Anabolic agents (growth stimulators)?	Yes No
Are you taking any sleeping pills?	Yes No
Are you taking any prescription drugs?	Yes No
Are you taking any non-prescription drugs not listed above?	Yes No
Have you, for medical reasons, not competed in a certain sport(s) for any period to time?	Yes No
Do you wear glasses for sports?	Yes No
Do you wear contact lenses for sports?	Yes No

		Details if “Yes”: dates, severity, medical tests, etc.
Diabetes, goitre or any other disease of the glands? (eg. Mononucleosis)	Yes No
Epilepsy?	Yes No
Nervous disorder or any diseases of the brain or nervous system?	Yes No
Heart trouble or rheumatic fever?	Yes No
Varicose veins, phlebitis, hemorrhoids?	Yes No
Any diseases of the blood, easy bruising or bleeding tendency?	Yes No
Asthma, tuberculosis or any lung disease or respiratory disorder?	Yes No
Ulcers or diseases of the stomach, intestines, liver or gall bladder?	Yes No
Sugar, albumin or blood in the urine or any diseases of kidneys/genito-urinary organs?	Yes No
Arthritis, rheumatism or any injury or disease of the bones, joints, back?	Yes No
Hernia or any disease of the muscles or skin?	Yes No
Cancer, tumor or growth of any kind?	Yes No
Have you ever had a head injury causing dizziness or requiring hospitalization? Yes No	severe dizziness loss of memory vomiting unconsciousness medical attention hospitalization	How many times? When?

		Details if “Yes”: dates, severity, medical tests, etc.
Have you ever had trouble with dehydration?	Yes No
Have you ever had heat stroke?	Yes No	Were you hospitalized for the heat stroke? Yes No
Other heat disorders? Please specify in details section.	Yes No
Have you ever been under observation in any hospital or similar institutions?	Yes No
Has your weight changed in the last year?	Yes No	kg Gain Loss
Are you more thirsty than usual lately?	Yes No
Are you involved in a sport based on weight class?	Yes No	What is your present weight? Kg At what weight do you intend to compete? Kg
Do you feel you a weight gain or loss would allow you to perform better?	Yes No	How much weight? Kg Gain Loss

		Details if “Yes”: dates, severity, medical tests, etc.
Have you ever injured your upper extremity? Yes No	shoulder arm elbow wrist hand	Did the injury incapacitate you for a week or longer? Yes No
Have you ever injured your head/torso? Yes No	head neck ribs lower back sacroiliac joints	Details:
Do you experience pain in you lower back?	Yes No	When? very seldom occasionally frequently only after exercise
Have you ever injured your lower extremity? Yes No	hip thigh knee shin ankle foot	Did the injury incapacitate you for a week or longer? Yes No
Have you ever been told you injured cartilage (meniscus) in either knee?	Yes No
Do you have problems with your knee caps ?	Yes No
Do you have a pin, screw or plate e in your body as a result of bone or joint surgery?	Yes No
Have you had a fracture in the past 2 years?	Yes No
Have you had any surgical procedures?	Yes No