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Reg ODP Camp Medical History Questionnaire
Please complete the following PLAYER information. Please be VERY CAREFUL inputting dates. This form will auto fill 2019, please be sure that you submit the CORRECT YEAR.
Year of Birth *
Gender *
Date of Birth (CAREFUL to input correct YEAR) *
MM
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DD
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YYYY
Last Name *
Your answer
First Name *
Your answer
Email *
Your answer
Mobile Phone *
Your answer
Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? *
List medication allergies
Your answer
Do you take any prescribed medication on a permanent basis or semi-permanent basis (steriods, birth control pills, anti-inflammatories, antibiotics, etc.)? *
List medication and give reason
Your answer
Have you ever had an epileptic seizure? *
Have you ever been told by a doctor that you have epilepsy? *
List epilepsy medication
Your answer
Have you ever been treated for diabetes? *
Have you ever been told by a doctor that you were anemic? *
When were you told you were anemic?
MM
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DD
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Have you ever been told by a doctor that you have sickle cell anemia? *
Have you ever been told by a doctor that you have sickle cell trait? *
Do you have or have you ever had high blood pressure? *
List high blood pressure medication
Your answer
Do you have or have you ever had heart disease (heart murmur, Rheumatic fever)? *
Give date
MM
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DD
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YYYY
Do you have or have you ever had lung disease (pneumonia) *
Give date
MM
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DD
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YYYY
Do you have or have you ever had kidney disease (infectious) *
Give date
MM
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DD
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YYYY
Do you have or have you ever had liver disease (mononucleosis, hepatitis) *
Give date
MM
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DD
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YYYY
Do you have or have you ever been told by a doctor that you have asthma? *
List asthma medication
Your answer
Do you have or have you ever had a hernia or "rupture"? *
Has it been repaired?
Give date
MM
/
DD
/
YYYY
Have you been "knocked out" in the past three years? *
Give dates
MM
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DD
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YYYY
Give dates
MM
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DD
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YYYY
Give dates
MM
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DD
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YYYY
Have you had a concussion or other head injury in the past 3 years? *
Give dates
MM
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DD
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YYYY
Give dates
MM
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DD
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YYYY
Give dates
MM
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DD
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YYYY
Have you stayed overnight in the hospital due to a head injury? *
Give dates
MM
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DD
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YYYY
Give dates
MM
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DD
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YYYY
Have you ever had a neck injury involving bones, nerves, or disks that disabled you for a week or longer? *
List type of injury and give date(s)
Your answer
Do you wear glasses or contacts during competition? *
Do you wear a dental appliance? *
List each appliance (permanent bridges, braces, removable retainer, permanent retainer, removable partial plate, full plate, permanent crown or jacket)
Your answer
Have you had a broken bone or fracture in the past 2 years? *
What bones, include LEFT or RIGHT, and date(s)
Your answer
Have you had a shoulder injury in the past 2 years that disabled you for a week or longer? (dislocation, separation, etc.) *
List type of injury, include LEFT or RIGHT, and date(s)
Your answer
Have you ever had shoulder surgery? *
What was done and why, include LEFT or RIGHT, and date(s)
Your answer
Have you ever injured your back? *
List type of injury, include LEFT or RIGHT, and date(s)
Your answer
Do you have back pain? *
Have you injured your knee in the past 2 years? *
LEFT or RIGHT, and date(s)
Your answer
Have you been told by a doctor or athletic trainer that you injured the cartilage in your knee? *
LEFT or RIGHT, and date(s)
Your answer
Have you been told by a doctor or athletic trainer that you injured the ligaments in your knee? *
LEFT or RIGHT, and date(s)
Your answer
Have you had knee surgery? *
What was done, include LEFT or RIGHT, and date(s)
Your answer
Have you had a severe ankle sprain in the past 2 years? *
LEFT or RIGHT, and date(s)
Your answer
Do you have a pin, screw, or plate in your body? *
Where include date(s)
Your answer
Do you have other conditions that we should be aware of (ulcers, pregnancy, food or insect allergies, tendinitis, etc)? *
Specify and give date(s)
Your answer
Date of last tetanus immunization *
MM
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DD
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YYYY
Date of last polio immunization *
MM
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DD
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YYYY
Date of last mumps immunization *
MM
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DD
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YYYY
Date of last rubella immunization *
MM
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DD
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YYYY
Date of last measles immunization *
MM
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DD
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YYYY
By TYPING MY FULL NAME and DATE below I affirm the questions on this form have been answered completely and truthfully to the best of my knowledge. (PARENT) *
Your answer
By TYPING MY FULL NAME and DATE below I affirm the questions on this form have been answered completely and truthfully to the best of my knowledge. (PLAYER) *
Your answer
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