KIWC - Medical History Questionnaire
Wrestler's Name *
Your answer
Wrestler's USA Card Number *
Obtained from the USA Wrestling Membership website.
Your answer
Emergency Contact *
Your answer
Emergency Contact Phone Number *
Your answer
1. Are you allergic to any general medication (aspirin, sulfa, penicillin, etc.)? *
If so, please indicate what medication(s).
Your answer
2. Are you now on any prescribed medication on a permanent or semi-permanent basis? *
If so, please indicate the name of the medication and why it was prescribed.
Your answer
3. Have you ever had an epilecptic seizure or been informed that you might have an epilepsy? *
4. Have you ever been treated for diabetes? *
If so, please indicate the type(s) of insulin or pills you used.
Your answer
5. Has a medical doctor ever told you that you were anemic or had sickle cell anemia? *
6. Do you have or have you ever had high blood pressure? *
If so, list any medication for it that you take regularly.
Your answer
7. Do you have or have you ever had any of the following diseases? *
Required
8. Have you ever been informed by a medical doctor that you have asthma? *
If so, what medications, if any, do you take regularly.
Your answer
9. Do you presently have an unrepaired hernia? *
10. Have you ever been "knocked out" or experienced a concussion during the past 3 years? *
If so, give the dates of each.
Your answer
11. If the answer to 10 is "yes" did the attending physician have you stay overnight in a hospital? *
If yes, give the dates of each.
Your answer
12. Have you ever had an injury to your neck involving nerves, vertebrae (bones), or discs that incapacitated you for a week or longer? *
If yes, give the dates of each such injury.
Your answer
13. Do you war any dental appliance. If yes, select the appropriate appliance: *
Required
14. Do you wear contact lenses during competition? *
15. Have you ever had a fracture during the past 2 years? *
If yes, indicate which bone was broken and the date it happened.
Your answer
16. Have you had a shoulder dislocation, separation or other shoulder injury in the past 2 years that incapacitated you for a week or longer? *
If so, give the date of the injury.
Your answer
17. Have you ever had surgery to correct a shoulder condition? *
If so, give the dates and what was done.
Your answer
18. Have you ever had an injury to your back? *
19. Do you experience pain in your back? *
If yes, indicate frequency:
20. Have you injured your knee during the last 2 years with severe swelling as a result? *
21. Have you ever been told that you injured the ligaments and/or cartilage of either knee? *
22. Have you ever been advised to have surgery to correct a knee problem? *
If the answer to 22 is yes, has the surgery been completed?
List date of surgery.
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24. Have you experienced a severe sprain of either ankle during the past 2 years? *
25. Have you had any injury to your foot or toes in the past 2 years? *
If yes, explain.
Your answer
26. Do you have any chronic conditions that have not been mentioned above? *
If so, explain.
Your answer
Wrestler's Signature *
The questions on this form have been answered completely and truthfully to the best of my knowledge. This constitutes a legal signature of the medical history questionnaire. Type the name.
Your answer
Date of Wrestler's Signature *
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DD
/
YYYY
Parent/Guardian Signature *
The questions on this form have been answered completely and truthfully to the best of my knowledge. This constitutes a legal signature of the medical history questionnaire. Type the name.
Your answer
Date of Parent/Guardian Signature *
MM
/
DD
/
YYYY
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