Celtics Medical Form 2019
This questionnaire is made up of simple, but important, questions regarding your health that will help us better help you in case of injury. Please be honest and as precise as possible. We also ask of you, for your safety and for our knowledge, that should any of your health information change, you let us know immediately. Thank you!
Athlete's name *
Your answer
Medicare or Other Healthcare Coverage (please specify) Number *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
Athlete's Phone Number *
Your answer
Athlete's Email Address *
Your answer
Primary Emergency Contact Person's Name and Relation to Athlete *
Your answer
Primary Emergency Contact Person's Phone Number *
Your answer
Primary Emergency Contact Person's Email Address (in the case where athlete is less than 14 years of age on this day) *
If not applicable, write N/A
Your answer
Alternate Emergency Contact Person's Name and Relation to Athlete *
Your answer
Alternate Emergency Contact Person's Phone Number *
Your answer
Alternate Emergency Contact Person's Email Address (in the case where the athlete is less than 14 years of age on this day) *
If not applicable, write N/A
Your answer
Please list all known allergies, including to tape and/or glue *
If not applicable, write N/A
Your answer
In the case of allergies, do you have an Epi-Pen? *
If not applicable, select no
Please list all current medication, including for asthma *
If not applicable, write N/A
Your answer
Do you wear glasses? *
Do you wear contact lenses? *
Do you have hearing problems? *
Do you suffer from frequent fainting spells? *
Do you have epilepsy? *
Do you have any learning disabilities or concentration problems (dyslexia, ADD, ADHD,etc)? *
Please identify the number of previous concussions *
In the case of previous concussion(s), when was the last one? *
If not applicable, use January 1st of the following year
MM
/
DD
/
YYYY
In the case of previous concussion(s), in relation to the most recent one, how long did the symptoms last? *
If not applicable, write N/A
Your answer
Do you have asthma? *
Do you have diabetes? *
Do you suffer from cardiac or vascular problems? *
If so, we will contact you for detailed information
Do you have high blood pressure? *
Please list any surgeries you have undergone *
If not applicable, write N/A; if within the last year, please include surgery date
Your answer
Please list all injuries suffered in the past 2 years that required you to sit out of play for more than one week *
If not applicable, write N/A
Your answer
If you suffer from any other condition or disease, not listed above, please specify *
If not applicable, write N/A
Your answer
BY CHECKING YES, YOU ARE CONFIRMING THAT THE SUPPLIED INFORMATION IS CORRECT AND YOU UNDERSTAND THAT, SHOULD YOU BE UNABLE TO ANSWER QUESTIONS PERTAINING TO YOUR HEALTH, THE FIRST RESPONDER WILL RELY ON THE SUPPLIED INFORMATION TO ASSIST YOU WITH YOUR AILMENT. *
In such a case, unless otherwise specified by a parent or guardian in the case of an athlete that is less than 14 years old, your consent to assistance is implied.
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy