Sports Questionnaire Update Form
Athlete's Name *
Your answer
Grade *
Your answer
Date of Birth *
Athletic Activity *
Anticipated Level *
History Since Last Medical Exam
1. Any injuries requiring medical attention? *
2. Any illness lasting more than 5 days? *
3. Taking any medicine or under a physician care at this time? *
4. Any feeling of faintness, dizziness, or fatigue after heavy exertion? *
5. Wearing glasses or contact lenses? *
6. A surgical operation or fracture? *
7. Treated in a hospital or emergency room? *
8. Any reason why this person cannot participate in any sport? *
9. Any known allergies? *
10. Any chronic disease? *
Have you ever been diagnosed or are you currently suffering from a concussion? *
If yes to any of the above, describe:
Your answer
We understand clearly that the questions are asked in order to decide if this student is in a proper condition to participate in the athletic activity named at the top of this form. The answers are correct as of the date this form is signed. All answers will be kept confidential in your child's health record in the school health's office.
Signature of Parent/Guardian *
By adding your name this is your verified electronic signature
Your answer
Signature of student *
By adding your name this is your verified electronic signature
Your answer
Note: "Yes" answers to any of the questions above does not automatically disqualify the athlete from the activity indicated. This will require review and evaluation by the school physician.
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