ATHLETE REGISTRATION FORM

Athlete Medical Form HEALTH HISTORY

(To be completed by the athlete or parent/guardian/caregiver and brought to exam)

Athlete First & Last Name:

First Last

Preferred Name:

Athlete Date of Birth (mm/dd/yyyy):

Date

Gender:

Female Male Other

STATE PROGRAM:

E-mail:

example@example.com

ASSOCIATED CONDITIONS - Does the athlete have (check any that apply):

Autism Down Syndrome Fragile X Syndrome Cerebral Palsy Fetal Alcohol Syndrome Other syndrome, please specify

Allergies & Dietary Restrictions

No Known Allergies Latex Medications Insect Bites or Stings Food

Please list Medication allergies:

Please list Insect Bite or Sting allergies:

Please list Food allergies:

List any special dietary needs:

ASSISTIVE DEVICES - Does the athlete use (check any that apply):

List all Special Olympics sports the athlete wishes to play:

Has a doctor ever limited the athlete's participation in sports?

No Yes (please describe)

List all past surgeries:

Does the athlete currently have any chronic or acute infection?

No Yes (please describe)

Has the athlete ever had an abnormal Electrocardiogram (EKG) or Echocardiogram (Echo)?

No Yes (please describe)

Has the athlete had a Tetanus vaccine in the past 7 years?

No Yes

Epilepsy or any type of seizure disorder

No Yes (please describe)

If yes, had seizure during the past year?

No Yes

Self-injurious behavior during the past year

No Yes

Aggressive behavior during the past year

No Yes

Depression (diagnosed)

No Yes

Anxiety (diagnosed)

No Yes

Describe any additional mental health concerns:

Has any relative died of a heart problem before age 50?

No Yes

Has any family member or relative died while exercising?

No Yes

List all medical conditions that run in the athlete’s family:

Athlete Medical Form HEALTH HISTORY

Athlete’s First and Last Name:

First Name Last Name

Has the athlete ever been diagnosed with or experienced any of the following conditions?

	No	Yes
Loss of Consciousness
High Blood Pressure
Stroke/TIA
Dizziness during or after exercise
High Cholesterol
Concussions
Headache during or after exercise
Vision Impairment
Asthma
Chest pain during or after exercise
Hearing Impairment
Diabetes
Shortness of breath during or after exercise
Enlarged Spleen
Hepatitis
Irregular, racing or skipped heart beats
Single Kidney
Urinary Discomfort
Congenital Heart Defect
Osteoporosis
Spina Bifida
Heart Attack
Osteopenia
Arthritis
Cardiomyopathy
Sickle Cell Disease
Heat Illness
Heart Valve Disease
Sickle Cell Trait
Broken Bones
Heart Murmur
Easy Bleeding
Dislocated Joints
Endocarditis

If female athlete, list date of last menstrual period:

Date

Describe any past broken bones or dislocated joints (if yes is checked for either of those fields above):

List any other ongoing or past medical conditions:

Neurological Symptoms for Spinal Cord Compression and Atlanto-axial Instability

	No	Yes	This is NOT new or worse in the past 3 years	This IS new or worse in the past 3 years
Difficulty controlling bowels or bladder
Numbness or tingling in legs, arms, hands, or feet
Weakness in legs, arms, hands, or feet
Burner, stinger, pinched nerve or pain in the neck, back, shoulders, arms, hands, buttocks, legs or feet
Head Tilt
Spasticity
Paralysis

PLEASE LIST ANY MEDICATION, VITAMINS OR DIETARY SUPPLEMENTS BELOW (includes inhalers, birth control or hormone therapy)

Please include medication name, dosage, and number of times/day

Is the athlete able to administer his or her own medications?

No Yes

Name of Person Completing this Form

Relationship to Athlete

Phone

Email

example@example.com

ATHLETE REGISTRATION FORM

ATHLETE INFORMATION

Parent / Guardian Information (required if athlete is a minor or otherwise has a legal guardian)

Emergency Contact Information

Physician & Insurance Information

SPORTS PARTICIPATION

SURGERIES, INFECTIONS, VACCINES

EPILEPSY AND/OR SEIZURE HISTORY

MENTAL HEALTH

FAMILY HISTORY