Active Athlete Medical History

Medical History

Please answer the following questions about your Medical History.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Do you have any of the following medical disorders: Heart Problems; High Blood Pressure; Diabetes; Hepatitis; Mental or Emotional Problems; Indigestion, Heartburn, or Ulcers; Lung Disease; Epilepsy; Kidney Disease; Tuberculosis; Cancer. Select all that apply.*

Heart ProblemsHigh Blood PressureDiabetesHepatitisMental or Emotional ProblemsIndigestion, Heartburn, or UlcersLung DiseaseEpilepsyKidney DiseaseTuberculosisCancerNone of the Above
If you've had cancer, what region?
Previous Surgeries, Date and Reason*
Previous Hospitalizations, Date and Reason*
Present Medications, Supplements or Vitamins*
Drug or Food Allergies (Please List)*
Current Review of Systems: Chronic Fever, Unexpected Weight Loss/Gain, Fatigue; Ear/Nose/Throat Problems (Hearing Loss, Sinuses, Sore Throat); Respiratory Problems (Shortness of Breath, Wheezing, Coughing); Gastrointestinal Problems (Heartburn, Abdominal Pain, Diarrhea); Urinary Problems (Pain or Blood with Urination); Skin Problems (Rashes, Excessive Dryness, Discoloration); Musculoskeletal Problems (Muscle Aches, Joint Pain); Neurological Problems (Numbness, Weakness, Headaches); Psychiatric Problems (Depression, Anxiety). Select all that apply.*

Chronic Fever, Unexpected Weight Loss/Gain, FatigueEar/Nose/Throat Problems (Hearing Loss, Sinuses, Sore Throat)Respiratory Problems (Shortness of Breath, Wheezing, Coughing)Gastrointestinal Problems (Heartburn, Abdominal Pain, Diarrhea)Urinary Problems (Pain or Blood with Urination)Skin Problems (Rashes, Excessive Dryness, Discoloration)Musculoskeletal Problems (Muscle Aches, Joint Pain)Neurological Problems (Numbness, Weakness, Headaches)Psychiatric Problems (Depression, Anxiety)None of the Above
If Yes to any of the above, please explain.
For Females: Please list the date of last normal menstrual period and age of onset menstruation if applicable.
Do any medical diseases run in your family (i.c., diabetes, high blood pressure, allergies, asthma, cancer, heart problems, glaucoma, prostate cancer)? Please Explain.*
Do You Smoke*

YesNo
If Yes, how many packs per day? How long?
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Medical Doctor Signature / Date
Please verify that you are human*
Should be Empty:

Medical History

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