Player Medical Form

MRHL Player Medical History
Player Name*

First NameLast Name
Player Birth Date*

MonthDayYear
Emergency contact name
Emergency contact phone number
Please list any allergies - medication, food, pollen, etc
If you have an epi-pen, please note that and where you keep it.
Please check the applicable responses and provide details below:

MedicationsHistory of concussionsDiabetesFainting/SeizuresNear faintingWear glassesWears contactsWears dental applianceHearing ProblemAsthmaTrouble breathing during exerciseHeart ConditionsPalpitations or Racing heartFamily History of unexpected death during physical activity
If you selected any of the above, please provide details you feel are relevant.
Please list any previous sports injuries, approximate dates, and whether or not it is still a problem.
If you have had a concussion or concussions, please list the date(s) and circumstance(s) as accurately as possible.
Please share any other details you feel are relevant.
Do you consent to have this information shared with MRHL staff, coaches, volunteers and if necessary, medical personnel, EMT's, or hospital staff?*

YesNo
Should be Empty:

MRHL Player Medical History