ECM Sports Performance and Rehabilitation Medical History Form
Full Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
Gender?
*
Please Select
Male
Female
N/A
Occupation
Contact Number
*
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you currently taking any medication?
*
Yes
No
Please list them.
List the symptoms that you're currently experiencing:
*
Check the conditions that apply to you:
*
Arthritis
Asthma
Cancer
Cardiac disease
Diabetes
Epilepsy
Fatigue
Headaches
Heart Disease
High Blood Pressure
Hypertension
Numbness
None
Other
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
What is your current activity level?
*
1-3 Days
3-5 Days
>5 Days
Not currently active
Are you currently participating in recreational or organized sports?
*
Yes
No
If answered yes, please list recreational activities or organized sports you participate in:
Emergency Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Patient Signature
Parent or Guardian Signature if under 18
Continue
Continue
Should be Empty: