Jones Co. Jr. College Sports Medicine Medical History Questionairre

Size: px
Start display at page:

Download "Jones Co. Jr. College Sports Medicine Medical History Questionairre"

Transcription

1 Jones Co. Jr. College Sports Medicine Medical History Questionairre DEMOGRAPHIC INFORMATION Full Name: Social Security #: - - Date of Birth: Sport: Year in School: Home Phone #: Cell Phone #: Parent/Guardian Name(s): Permanent Address: City: State: Zip: FAMILY HISTORY Has anyone in your immediate family ever been diagnosed with any of the following? Circle Yes or No Heart Disease Yes No Diabetes Yes No High Blood Pressure Yes No Cancer Yes No Stroke Yes No Tuberculosis Yes No Sudden Death (before age 50) Yes No Asthma Yes No Epilepsy Yes No Gout Yes No Migraine Headaches Yes No Mental Illness Yes No Eating Disorder Yes No Sickle Cell Anemia Yes No Marfan s Syndrome Yes No Drug/Alcohol Abuse Yes No PERSONAL HISTORY Allergies List any other allergies that you may have: Medications Do you currently take any prescription medications? Yes No If yes, please indicate which medication(s) you take and for what reason: Do you currently take any over-the-counter medications? Yes No If yes, please indicate which medication(s) you take and for what reason: Do you take any supplements (i.e., vitamins, creatine, protein, weight gainer)? Yes No If yes, please indicate which supplements or vitamins:

2 General Medical Have you ever been diagnosed with any of the following medical conditions? (Circle Yes or No) Mononucleosis Yes No Diabetes Yes No Anemia Yes No Rheumatic Fever Yes No Ulcers Yes No Hernia Yes No Sickle Cell Anemia Yes No Marfan s Syndrome Yes No Migraine Headaches Yes No Depression Yes No Kidney Disease Yes No Tuberculosis Yes No Hepatitis Yes No Crohn s Disease Yes No Chicken Pox Yes No Jaundice Yes No Measles Yes No High Blood Pressure Yes No Pneumonia Yes No Heart Palpitation Yes No Mumps Yes No Appendectomy Yes No Heat Stroke Yes No Scarlet Fever Yes No Chest Pain Yes No Epilepsy/Seizures Yes No Please explain all Yes answers Please list any other medical illness or condition that you may have had that is not listed in this questionnaire: Have you ever suffered from a Heat Illness (i.e., Heat Stress, Heat Exhaustion, and Heat Cramps)? Yes No Have you ever suffered from Muscle Cramps? Yes No Have you ever had shortness of breath or unusual fatigue with exercise? Yes No Please explain all Yes answers, including when it occurred: Has anyone in your family suffered a premature (50 years or younger) death or significant disability from a heart condition? Yes No Do you know of any close relatives with heart conditions? Yes No Have you ever been told that you have a heart condition? Yes No Have you ever passed out during or after any exercise session? Yes No Have you ever been dizzy during or after any exercise session? Yes No Have you ever had chest pain or discomfort during or after any exercise session? Yes No Have you ever been diagnosed with high blood pressure? Yes No Have you ever been diagnosed with racing of your heart or skipping heartbeats? Yes No Have you ever had chest pain while exercising? Yes No Have you ever been told you have a heart murmur? Yes No Have you ever had high cholesterol? Yes No Have you ever missed any practices or games due to any of the above conditions? Yes No Have you ever undergone any testing on your heart? Yes No Have you ever seen a Doctor for any of the above conditions? Yes No Please explain all Yes answers, including when it occurred: Do you have a history of Asthma? Yes No If yes, do you currently use an inhaler? Yes No Please list the medication used and how often: If yes, please provide dates: Are you missing or have impaired function of any paired organ (i.e., kidney)? Yes No Have you ever had any unusual or internal bleeding? Yes No If yes, please explain: Have you ever been hospitalized for any reason? Yes No Have you ever had surgery on any body part? Yes No

3 Are you currently under a Doctor s care for any reason? Yes No Please list the following information, if applicable: Do you have a family doctor? Yes No Name of Family Doctor: Phone #: Address: City: State: Zip: Vision History Do you wear glasses or contacts? Yes No Which? Do you wear them during competition? Yes No What is the date of your last eye exam? Dental History Do you currently suffer from any dental problems? Yes No Do you wear a mouthpiece or other dental protective device other than equipment required by your sport? Yes No Orthopedic/Injury History Do you have a family orthopedic doctor? Yes No Name of Orthopedic Doctor: Phone #: Address: City: State: Zip: Have you ever had surgery on any body part for an injury suffered during sports participation? Yes No Do you have a pin, screw, or plate in any part of your body? Yes No If yes, please explain, including dates: Have you ever had an x-ray, CT Scan, or MRI Scan taken on any body part, including your head, neck, and spine? Yes No If yes, please explain, including dates: Do you require any special taping or protective devices, such as a brace, for sports participation? Yes No Please indicate any injuries to the following: Head: Skull Fracture Yes No Internal bleeding of the skull Yes No Concussion Yes No Knocked Unconscious Yes No Other: Please explain all Yes answers, including when they occurred: Were you treated by a doctor following these head injuries? Yes No What doctor were you treated by? How many games and/or practices did you miss due any head injuries? Neck: Fracture Yes No Burners/Stingers Yes No Pinched Nerve Yes No Numbness/Tingling/Burning Yes No Other:

4 Back: Scoliosis Yes No Spina Bifida Yes No Disc Injury Yes No Degenerative Disc Yes No Muscular Injury Yes No Numbness/Tingling/Burning Yes No Other: Shoulder: Dislocation Yes No Subluxation Yes No Separation Yes No Rotator Cuff Injury Yes No SLAP Lesion Yes No Thoracic Outlet Syndrome Yes No Fracture Yes No Other: Elbow/Wrist: Fracture Yes No Sprain Yes No Dislocation Yes No Other: Hip: Dislocation Yes No Hip Pointer Yes No Degenerative Joint Yes No Other: Knee: Osgood s Schlatter Disease Yes No Ligament Injury Yes No Cartilage Injury Yes No Patella (knee cap) Injury Yes No Subluxation Yes No Dislocation Yes No Muscular (Hamstring, Quad) Yes No Other: Foot/Ankle: Sprain Yes No Dislocation Yes No Fracture Yes No Achilles Tendon Injury Yes No Shin Splints Yes No Plantar Fasciitis Yes No Flat Feet Yes No High Arches Yes No Other: Please List any other injuries not listed above:

5 Sickle Cell Trait Do you have a parent with sickle cell trait or sickle cell anemia? Yes No Have you been told you have sickle cell trait? Yes No Have you been tested for sickle cell trait? Yes No If you do not know if you have been tested or you have not been tested for sickle cell trait, testing is recommended. Please check one of the following options and sign and date below. I, would like to be tested for sickle cell trait. Print athlete s name I, do not wish to be tested for sickle cell trait. Print athlete s name PHYSICAL SCREENING WAIVER FORM To the best of my knowledge, I have given true and complete information, and hereby grant my permission for the athletic health screening. We acknowledge this examination is for screening purposes only and does not take the place of your normal complete periodic exam/annual well-child exam. This screening exam is for clearing athletes to participate in sports and does not represent the total health of the child. This exam is not meant to be a comprehensive physical exam. The passing of the physical examination does not necessarily mean that the child is qualified to engage in athletics, but only that the physician did not find a medical reason to disqualify the child at the time of the examination. The normal history and examination does not mean that a potentially life threatening health problem is not present. There are no studies that have shown that these screening exam requirements reduce sudden cardiac death. We agree to allow Hattiesburg Clinic to release a copy of this screening to the athlete s school, which is required for participation. This waiver, executed by Hattiesburg Clinic, PA and the athlete is executed in compli9ance with Mississippi law, which provides a physician voluntarily provides needed medical or health services to any program at an accredited school in the state without expectation of payment the physician will be immune from any liability for any civil action arising out of the provision of those medical and/or health care services which were provided in good faith on a charitable basis. Such immunity does not extend to act of willful or gross negligence. Print Name Student- Athlete Signature Date

INITIAL MEDICAL PACKET

INITIAL MEDICAL PACKET P a g e 1 INITIAL MEDICAL PACKET Name: Sport: Date: Last First Middle SSN: - - DOB: / / Age: Cell Phone: ( ) - Home Phone: ( ) - Family Physician: Phone: ( ) - Emergency contact: Name: Phone: ( ) - Relationship:

More information

Pre-participation Physical Evaluation

Pre-participation Physical Evaluation Pre-participation Physical Evaluation HISTORY FORM Date of Exam: Name Sex Age Date of Birth Grade School Sport(s) Address Phone Personal Physician In case of emergency, contact: Relationship Phone (H)

More information

Upper Iowa University Athletic Training. Name: Last First Middle. Home Address: Street Address City State Zip

Upper Iowa University Athletic Training. Name: Last First Middle. Home Address: Street Address City State Zip Upper Iowa University Athletic Training MEDICAL HISTORY Personal Data Name: Last First Middle Home Address: Street Address City State Zip School Address: Street Address City State Zip Home Phone #: Cell

More information

Celebration Lutheran School

Celebration Lutheran School Celebration Lutheran School Wisconsin Interscholastic Athletic Association Athletic History and Physical Examination Approval for TWO YEARS of Competition All students participating in interscholastic

More information

UWSP Medical History Form

UWSP Medical History Form UWSP Medical History Form 2017-2018 Student: Please complete the first 6 pages prior to your appointment with your medical provider. The medical provider must sign off on the medical history form. Student

More information

AVORS MEDICAL GROUP Antelope Valley Orthopaedic & Rehabilitation Specialists

AVORS MEDICAL GROUP Antelope Valley Orthopaedic & Rehabilitation Specialists Work Physical Patient Forms Packet -- Page 1 of 6 AVORS MEDICAL GROUP Antelope Valley Orthopaedic & Rehabilitation Specialists Alon Antebi, DO Thomas S. Nasser, DO Ajay K. Masih, MD Justin Heller, MD Justin

More information

AVORS MEDICAL GROUP Antelope Valley Orthopaedic & Rehabilitation Specialists

AVORS MEDICAL GROUP Antelope Valley Orthopaedic & Rehabilitation Specialists Sports Physical Patient Forms Packet -- Page 1 of 7 AVORS MEDICAL GROUP Antelope Valley Orthopaedic & Rehabilitation Specialists Alon Antebi, DO Thomas S. Nasser, DO Ajay K. Masih, MD Justin Heller, MD

More information

CONTENTS ALL PARTS OF THIS PACKET ARE IMPORTANT, AND IT MUST BE COMPLETED IN ITS ENTIRETY!

CONTENTS ALL PARTS OF THIS PACKET ARE IMPORTANT, AND IT MUST BE COMPLETED IN ITS ENTIRETY! 2017-18 Point Park University Athletics Medical Packet Enclosed you will find many of the necessary forms needed to compete in intercollegiate athletics during the 2017-18 year. Please return all completed

More information

Oxford Golden Bears Comprehensive Initial Pre-Participation Physical Evaluation

Oxford Golden Bears Comprehensive Initial Pre-Participation Physical Evaluation 2018 Comprehensive Initial Pre-Participation Physical Evaluation SECTION 1: PERSONAL AND EMERGENCY INFORMATION ATHLETE S PERSONAL INFORMATION Name Male/Female (circle one) Date of Birth / / Age on Last

More information

Pre-participation Physical Examinations

Pre-participation Physical Examinations Pre-participation Physical Examinations www.acsm.org Past Medical History History of any of the following should be made available to the healthcare provider: allergy allergies to medications asthma birth

More information

have completed a physical exam on Print Physicians Name on. Name of Patient

have completed a physical exam on Print Physicians Name on. Name of Patient This form must be filled out by the physician that completed the physical and returned to the ATP Director by the patient. This form will be kept on record in the students permanent program file. Please

More information

Did you complete the Sports Ware Online required information (

Did you complete the Sports Ware Online required information ( Dear New VSU Student Athlete and Parent/Guardian, Welcome to Virginia State University. It is important that a safe and knowledgeable environment is maintained for you, the student-athlete, the athletic

More information

Huntsville High School Swim and Dive Check List. Name:

Huntsville High School Swim and Dive Check List. Name: Huntsville High School Swim and Dive Check List Name: Code of Conduct Physical Signed by Doctor Athletics Permission Form Liability Release Form 7 th Period Release Form Travel Form Medical Form Copy of

More information

Durham Public Schools Assumptions of Risk/Medical Treatment Release

Durham Public Schools Assumptions of Risk/Medical Treatment Release Durham Public Schools Assumptions of Risk/Medical Treatment Release Student Athlete Name School Sport(s) Date The Durham Public Schools system makes every effort to prevent injuries, but injuries do occur

More information

Mount Mystics MSVU Athletics & Recreation

Mount Mystics MSVU Athletics & Recreation Mount Mystics 2015-2016 MSVU Athletics & Recreation Student Athlete Medical History Card Please complete the first 3 pages and bring to entire document to the doctor s office. Athlete Information Sport:

More information

Spring Hill College Athletic Training Department NCAA Division II Tryout

Spring Hill College Athletic Training Department NCAA Division II Tryout Dear Parent/Guardian: Spring Hill College Athletic Training Department NCAA Division II Tryout I want to first welcome you to Spring Hill College and its athletic department; this is an exciting time for

More information

TRYOUT REQUEST COVERSHEET FOR PROSPECTIVE STUDENT

TRYOUT REQUEST COVERSHEET FOR PROSPECTIVE STUDENT TRYOUT REQUEST COVERSHEET FOR PROSPECTIVE STUDENT To be completed by Student prior to tryout Name Date Date of Birth Sport School Currently Attending Registered with NCAA Eligibility Center o Yes o No

More information

University of Nebraska Omaha Athletic Performance Pre-Participation Medical History & Physical Examination Form TEAM TRYOUTS

University of Nebraska Omaha Athletic Performance Pre-Participation Medical History & Physical Examination Form TEAM TRYOUTS Name (Last, First, MI) University of Nebraska Omaha Athletic Performance Pre-Participation Medical History & Physical Examination Form TEAM TRYOUTS of Birth Address Sex M / F Sport Phone City State Zip

More information

NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM

NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM Patient s Name: Age: Sex: This is a screening examination for participation in sports. This does not substitute for

More information

Rise Chiropractic 239 S. French Broad Ave Asheville, NC

Rise Chiropractic 239 S. French Broad Ave Asheville, NC Rise Chiropractic 239 S. French Broad Ave Asheville, NC 28801 828.989.8369 1 Name: of Birth: Age: Sex: M F Address: City/State: Zip: Phone: (H) (W) (C) SS# Email: Occupation: Employer: Marital Status:

More information

Pre-Participation Medical Questionnaire Team Canada Volleyball Centralized Training

Pre-Participation Medical Questionnaire Team Canada Volleyball Centralized Training Pre-Participation Medical Questionnaire Team Canada Volleyball Centralized Training This form should be completed by the athlete and presented to the physician during his/her medical exam. Player I.D.

More information

ICSA Sports Physical Examination

ICSA Sports Physical Examination Learning and Leading in a Collaborative Culture ICSA Sports Physical Examination (Circle One) MALE FEMALE What Sport do you plan to play? Student s Name: Date of Birth: M D Y Age: Grade / Class Address:

More information

NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM

NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM Patient s Name: Age: This is a screening examination for participation in sports. This does not substitute for a

More information

FRESHMEN/TRANSFER STUDENT CHECKLIST

FRESHMEN/TRANSFER STUDENT CHECKLIST FRESHMEN/TRANSFER STUDENT CHECKLIST Pre Participation Questionnaire Medical Consent Form Insurance Form Please include a copy of the FRONT and BACK of your insurance card. Pre Participation Physical Form

More information

STRENGTH & CONDITIONING INFORMATION AND PRE-ACTIVITY SCREENING

STRENGTH & CONDITIONING INFORMATION AND PRE-ACTIVITY SCREENING STRENGTH & CONDITIONING INFORMATION AND PRE-ACTIVITY SCREENING Please take the time to read through all the information and ensure all relevant forms are completed. The following questionnaire and waivers

More information

First Year Varsity Athletics Pre-participation Medical Examination

First Year Varsity Athletics Pre-participation Medical Examination First Year Varsity Athletics Pre-participation Medical Examination Background 1. Name: E-mail address: 2. Date of Birth / / 3. Gender: Male Female 4. Academic Class (for the upcoming year) Freshman Sophomore

More information

Illinois State University. Athletic Training Education Program

Illinois State University. Athletic Training Education Program Illinois State University Athletic Training Education Program Procedures for Determining that the Health Status of an Athletic Training Student will permit him or her to meet the Established Technical

More information

MALONE SPORTS MEDICINE Pre-Participation Physical Exam Form ATHLETE PREVIOUS MEDICAL HISTORY (To be completed by the athlete)

MALONE SPORTS MEDICINE Pre-Participation Physical Exam Form ATHLETE PREVIOUS MEDICAL HISTORY (To be completed by the athlete) MALONE SPORTS MEDICINE Pre-Participation Physical Exam Form 2018-2019 ATHLETE PREVIOUS MEDICAL HISTORY (To be completed by the athlete) Athlete Name: LAST FIRST MI Sport(s): SSN: OPTIONAL Birthdate: MONTH

More information

ATHLETIC CONTRACT. I will strive to give my best to the team in every practice and every game.

ATHLETIC CONTRACT. I will strive to give my best to the team in every practice and every game. ATHLETIC CONTRACT Please initial each statement below to acknowledge your agreement to this contract. Then, sign the form at the bottom and return to the Athletic Director to be eligible for participation.

More information

Chiropractic Registration and History

Chiropractic Registration and History Chiropractic Registration and History 1. Patient Information Name: Birthdate: SS/HIC/Patient ID #: Address: City: State: Zip: Phone: Cell: E-Mail: Sex: M F (Circle) Minor Single Married Divorced Separated

More information

PATIENT REGISTRATION

PATIENT REGISTRATION PATIENT REGISTRATION Last Name First Name MI Street Address City State Zip Code Social Security # - - Email Address Home Phone( ) Cell Phone( ) Sex Male Female of Birth Age Marital Status Married Single

More information

Registration and History Form

Registration and History Form Registration and History Form PATIENT INFORMATION Date: / / Patient Address City State Zip Sex M F Age Birthdate Occupation _ Employer Spouse s Name _ Sex M F Age Birthdate Occupation Spouse s Employer

More information

MARINA HS SPORTS PHYSICALS

MARINA HS SPORTS PHYSICALS MARINA HS SPORTS PHYSICALS WHEN May 30 th, 2018 @ 4pm8pm WHERE Marina Gymnasium COST $30 cash or check WHAT TO BRING Peach PHYSICAL FORM (with front side filled out) $30 CASH or CHECK made out to Marina

More information

The New Mexico Activities Association physical form provides schools, parents and providers with a recommended form.

The New Mexico Activities Association physical form provides schools, parents and providers with a recommended form. The New Mexico Activities Association physical form provides schools, parents and providers with a recommended form. If the NMAA recommended Physical Form is to be used, please ensure that your child s

More information

MEDICAL HISTORY QUESTIONNAIRE

MEDICAL HISTORY QUESTIONNAIRE MEDICAL HISTORY QUESTIONNAIRE Please print and complete this questionnaire prior to your first physical therapy appointment. The purpose of this questionnaire is to help us understand your health status.

More information

THE UNIVERSITY OF ALABAMA SPORTS MEDICINE MEDICAL HISTORY

THE UNIVERSITY OF ALABAMA SPORTS MEDICINE MEDICAL HISTORY THE UNIVERSITY OF ALABAMA SPORTS MEDICINE MEDICAL HISTORY / / Date Sport NAME: Last First Middle S.S. Number / / Date of Birth / / Age Sex- Male/ Female School Address Phone( ) Mother/Guardian Phone( )

More information

Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?

Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start? Name Date / / Age Male / Female Address City State Zip Phone: Home Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single / Married / Divorced / Widowed Spouse s Name

More information

Student s Name Male Female Date of Birth Grade. Parent s/guardian s Name Date Phone # Family Physician Phone #

Student s Name Male Female Date of Birth Grade. Parent s/guardian s Name Date Phone # Family Physician Phone # IOWA ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION ARTICLE VII 36.14(1) PHYSICAL EXAMINATION. Every year each student (grades 7-12) shall present to the student s superintendent a certificate signed

More information

Edward Waters College Athletic Training General Information Form

Edward Waters College Athletic Training General Information Form Edward Waters College Athletic Training General Information Form Mobile Phone: ( ) Classification: Student-Athlete Name (Last, First, Middle): Sport: of Birth: / / Social Security Number: Permanent Address

More information

Dear Student-Athlete,

Dear Student-Athlete, Dear Student-Athlete, Welcome to Widener University. In order to keep you safe on and off the field there are certain physical requirements you must fulfill before participating in club sports. Please

More information

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age:  address: Occupation: Employer: Spouse's Employer: Referred by: CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.

More information

Patient Information. Name: Last First MI. Address: Street City State Zip

Patient Information. Name: Last First MI. Address: Street City State Zip Date: WELCOME TO: Name: Address: Patient Information Last First MI Street City State Zip Phone # : (Mobile) (Home) (Work) Can we leave a voicemail or text message? Yes No Email: Date of Birth: Gender:

More information

Back In Balance Chiropractic, LLC

Back In Balance Chiropractic, LLC Back In Balance Chiropractic, LLC Date Name What do you prefer to be called Address City State Zip Code Birth Date: / / Social Security Number: - - Height: Weight: E-mail Home Phone ( ) - Cell ( ) - Contact

More information

Regards, ext ext. 1160

Regards, ext ext. 1160 FOR: FROM: RE: Current/Prospective Medina Valley ISD Student-Athletes and Parents Randy Neuman, ATC, LAT, & Monica Valdez LAT, M. Ed. Athletic Physicals for the 2018-2019 school year Dear Athletes and

More information

PART I - ATHLETIC PARTICIPATION (To be filled in and signed by the student)

PART I - ATHLETIC PARTICIPATION (To be filled in and signed by the student) HRLax High School League Athletic Participation/Parental Consent/Medical Release Form Separate signed form is required for each school year May 1 of the current year through June 30 of the succeeding year.

More information

New Patient Form Welcome!

New Patient Form Welcome! New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had

More information

Current Health Information

Current Health Information Name: : / / Current Health Information List your health concerns below: Health Concerns: (List according to severity) Rate of Severity 1 = Mild 10 = Unbear able When did the Symptom s Start? Are the Symptoms

More information

Dr. Brett Whitekettle

Dr. Brett Whitekettle Dr. Brett Whitekettle For Office Use Only: Patient ID #: 200 Cape Fear Circle Suite 2 Sneads Ferry, NC 28460 T: (910) 327-0022 F: (910) 327-0337 office@whitekettlechiropractic.com Patient Information Phone

More information

Certificate of Health Examination and Immunity

Certificate of Health Examination and Immunity AURORA UNIVERSITY and GEORGE WILLIAMS COLLEGE of AURORA UNIVERSITY School of Nursing Certificate of Health Examination and Immunity Student to complete pages 1-3 Name: Date of Birth: / / Sex: M F SS#:

More information

Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy

Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy Patient Number: Date of First Visit: Last Name: First Name: MI: Address: City: State: Zip Code: Email address: Phone: H

More information

Date of Exam: Name: Date of Birth Sex Age Grade School

Date of Exam: Name: Date of Birth Sex Age Grade School Pre-Participation Physical Evaluation-To Be Retained By Physician HISTORY FORM (Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this

More information

PATIENT INFORMATION FORM (PLEASE PRINT)

PATIENT INFORMATION FORM (PLEASE PRINT) PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE

More information

Liver Health: Do you have liver problems? Yes No If so, please specify:

Liver Health: Do you have liver problems? Yes No If so, please specify: Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their

More information

UNION MINE HIGH SCHOOL

UNION MINE HIGH SCHOOL UNION MINE HIGH SCHOOL Home of the DIAMONDBACKS umhs.eduhsd.k12.ca.us (select Athletics) Principal: Paul Neville Athletic Director: Jay Aliff FALL WINTER SPRING August 7, 2017 November 6, 2017 February

More information

Notto Chiropractic Health Center Patient Information

Notto Chiropractic Health Center Patient Information Notto Chiropractic Health Center Patient Information Acct #: Name: Preferred Name: Address: City: State: Zip: Home Phone: ( ) - _. Work Phone: ( ) -. Who Referred You? In Case of Emergency: Phone Number:

More information

Chiropractic Case History/Patient Information

Chiropractic Case History/Patient Information Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:

More information

ETSU Athletic Training Jerry Robertson BucSports Athletic Medicine Center

ETSU Athletic Training Jerry Robertson BucSports Athletic Medicine Center To: Potential ETSU Student Athlete From: Nathan Barger, MA, ATC Assistant Athletic Trainer for Football Re: Athletic Training Room Physical Paperwork Thank you for your interest in East Tennessee State

More information

Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip

Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation

More information

S Student Date of Birth (MM/DD/YYYY) Academic School Year Graduating Class

S Student Date of Birth (MM/DD/YYYY) Academic School Year Graduating Class Student Last Name Student First Name Middle Initial 2018-2019 S Student Date of Birth (MM/DD/YYYY) Academic School Year Graduating Class Student ID Number Sport(s) of Interest (please list all) Athletic

More information

Student Health Services Office 5400 Ramsey Street Fayetteville, North Carolina Phone: (910) or (910) FAX: (910)

Student Health Services Office 5400 Ramsey Street Fayetteville, North Carolina Phone: (910) or (910) FAX: (910) 1 Last Name: First Name: MU Student ID#: Student Phone #: Year Attending: Fall Spring Year Attended if Returning Student Student Athlete: y/n Sport: International Student: y/n Physician Assistant Student:

More information

Health Services & Sports Medicine Entrance / Pre-Participation Physical Exam

Health Services & Sports Medicine Entrance / Pre-Participation Physical Exam Full Name (First, Middle, Last): Health Services & Sports Medicine Entrance / Pre-Participation Physical Exam Sport (if athlete): Date of Birth: Social Security #: Home Address: Gender: Year in Sport:

More information

Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:

Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone: Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work

More information

The New Mexico Activities Association physical form provides schools, parents and providers with a recommended form.

The New Mexico Activities Association physical form provides schools, parents and providers with a recommended form. The New Mexico Activities Association physical form provides schools, parents and providers with a recommended form. If the NMAA recommended Physical Form is to be used, please ensure that your child s

More information

New Client Intake. First Name Last Name. Address. City State Zipcode Date of Birth. Home Phone Mobile Phone. Relationship to you Phone

New Client Intake. First Name Last Name. Address. City State Zipcode Date of Birth. Home Phone Mobile Phone. Relationship to you Phone 1 New Client Intake Address City State Zipcode Date of Birth Home Phone Mobile Phone Emergency Contact: Relationship to you Phone Please explain the pain you are experiencing and its origin story: https://docs.google.com/document/d/1q0tns8lwtefzbbj1n9jyt2onopvy2abs9s1ofr07zai/edit

More information

We urge you to bring your parents or guardians with you to your visit.

We urge you to bring your parents or guardians with you to your visit. Health Center 121st Street and Park Avenue Tacoma, Washington 98447 www.plu.edu/health 253-535-7337 NCAA Pre-participation Medical Examination Information 2017-18 Academic Year Dear New Athletes and Families,

More information

Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip

Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation

More information

N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro

N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.

More information

Name Age Birthday / / Sex Last First MI. Home Address Street Apt City State Zip Code Home phone: ( ) Cell phone: ( ) Name of parent(s) or guardian:

Name Age Birthday / / Sex Last First MI. Home Address Street Apt City State Zip Code Home phone: ( ) Cell phone: ( ) Name of parent(s) or guardian: I. HEALTH HISTY- To be completed by the STUDENT (Required of all full-time students) Please answer all questions. Information requested in this form is strictly for the use of the Health Center in providing

More information

Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:

Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number: Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:

More information

PATIENT INFORMATION FORM (WOMEN ONLY)

PATIENT INFORMATION FORM (WOMEN ONLY) PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for

More information

EMS Education. Immunization/Physical Policy 2016

EMS Education. Immunization/Physical Policy 2016 EMS Education Immunization/Physical Policy 2016 Immunizations: Students are required to have successfully completed immunizations or immunization series, as recommended by the Centers for Disease Control

More information

Essex Podiatry Associates Jeffrey N. Kaplan, DPM Neil E. Goldberg, DPM

Essex Podiatry Associates Jeffrey N. Kaplan, DPM Neil E. Goldberg, DPM General Vital Information Date: Name: Nickname: Sex: M / F SS #: DOB: E-mail: Home #: Address: Work #: City: State: Zip: Cell #: Primary Care Physician: PCP Phone: PCP Address: Last Visit: Emergency Contact

More information

Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:

Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:

More information

Dr. Fawn Shaffer, DC 565 McElhattan Drive Lock Haven, PA (570)

Dr. Fawn Shaffer, DC 565 McElhattan Drive Lock Haven, PA (570) PATIENT Dr. Fawn Shaffer, DC 565 McElhattan Drive Lock Haven, PA 17745 (570) 748-3590 PERSONAL INFORMATION: Please Circle: Mr. Mrs. Ms. Miss Dr. Male Female Name: Nickname: Age: DOB: Address: City/State/

More information

(emergency room pain)

(emergency room pain) Welcome to Moving Body Chiropractic! We re glad you re here. Whether you re looking to work on a specific problem or just feel great, this form is the start to your wellness journey! Please take the time

More information

Revelation Chiropractic Health Profile

Revelation Chiropractic Health Profile Revelation Chiropractic Health Profile Name Date / Age Male / Female Address Apt City Zip Phone Numbers: Home Cell Circle best number to reach you at: Home Cell Date of Birth / / Occupation Email Address

More information

- abnormal blood lipids/ cholesterol. - lightheadedness or fainting with exercise. -heart murmur. - rapid heart beats or palpitations.

- abnormal blood lipids/ cholesterol. - lightheadedness or fainting with exercise. -heart murmur. - rapid heart beats or palpitations. health medical questionnaire page 1 name date address- phone (day)- (evening)- sex- -- height- -- weight- date of birth - -age- occupation personal physician - address - _ phone (day)- date of last physical

More information

Dear Student-Athlete,

Dear Student-Athlete, Dear Student-Athlete, Welcome to Widener University. In order to keep you safe on and off the field there are certain requirements you must fulfill before participating in collegiate sports. Please see

More information

Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)

Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon) Name_ Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon) For reminders do you prefer Phone Calls, Text Messages or Emails? CALL ME / TEXT ME / EMAIL ME Email Address

More information

SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:

SMITH CHIROPRACTIC HEALTH PROFILE Today s Date: SMITH CHIROPRACTIC HEALTH PROFILE Today s Date: Name: Age: Male/Female DOB: Address: City: State: Zip: Home Phone:_ Cell: Cell Phone Provider: SSN#: Email Address: Single/Married/Divorced/Widowed Spouse

More information

PATIENT INFORMATION. Name Last First Middle. Address Number Street Name Apt# Home Phone Work Phone Cell Phone. Date of Birth / / Age Sex: Male Female

PATIENT INFORMATION. Name Last First Middle. Address Number Street Name Apt# Home Phone Work Phone Cell Phone. Date of Birth / / Age Sex: Male Female Today s Date PATIENT INFORMATION Name Last First Middle Address Number Street Name Apt# City State Zip Home Phone Work Phone Cell Phone Date of Birth / / Age Sex: Male Female Employed Full-Time Student

More information

INFORMATION/APPLICATION FOR CARE

INFORMATION/APPLICATION FOR CARE INFORMATION/APPLICATION FOR CARE The following information is needed in order to better serve you. Please complete all questions. If you need help please ask. Name Home Phone Work Phone Cell Phone E-Mail

More information

ATHLETIC PARTICIPATION FEE

ATHLETIC PARTICIPATION FEE Dear Celtics, Welcome to Trinity Catholic High School. We are looking forward to a great year. The following athletic activities will be offered in the upcoming school year. Fall Sports Season Winter Sports

More information

, -. /)! * )0 " # /#/# # #!!# "1 #)'!/#! /-)!2

, -. /)! * )0  # /#/# # #!!# 1 #)'!/#! /-)!2 0102345 78923 2388 277 70238427 2872 05228 78 47470! "" # "" $"%%%%%% &'!%%%%%%%%%% ( ) * #'"#%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% # * +#%%%%%%%%%%%%%%%%, -. /)! * )0 " # /#/# # #!!# "1 #)'!/#!

More information

Hamilton Back Clinic

Hamilton Back Clinic Hamilton Back Clinic Intake Form Name: City: Address: Postal Code: Phone: Sex: M F Date of Birth: Month/Day/Year E mail: Emergency Contact: Name/Phone: Name of Family Physician (MD): Employer: Employer

More information

Thai Massage Health History Questionnaire

Thai Massage Health History Questionnaire Name: Date: Thai Massage Health History Questionnaire Mobile Work Home Email Birthday Address Emergency Contact Name Relationship number Occupation How did you find me? When was your last massage? Where?

More information

New Patient Information and History Form

New Patient Information and History Form New Patient Information and History Form John K. Dorman, M.D., FACS Diplomate of The American Board of Neurological Surgery 400 Rosalind Redfern Grover Parkway Suite 200 Midland, TX 79701 432 687-2350

More information

Employed? Yes No Employer Name. Occupation. Problem Onset Frequency Severity E.g. Headaches June times per week Mild / Moderate / Severe

Employed? Yes No Employer Name. Occupation. Problem Onset Frequency Severity E.g. Headaches June times per week Mild / Moderate / Severe PLEASE NOTE: This file must be saved to your desktop before and after completing! PATIENT INFORMATION Date First Name SSN Sex Marital Status Middle Name Birth Date Last Name Height Spouse Name Address

More information

Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:

Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax: Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic 690 15355 24 th Avenue Surrey BC V4A 2H9 Tel: 604.541.9336 Fax: 604.541.9308 I. Patient Information Thank you for choosing our practice for

More information

CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE

CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT

More information

Chiropractic Case History/Patient Information

Chiropractic Case History/Patient Information 1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Cell Phone: Age: Birth Date: Race: Marital Status: [M] [S ][W] [D] Occupation:

More information

intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code: Address:

intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code:  Address: intake form Page 1`of 5 About You : Name: Sex: Male Female Address: City: State/Province: Country: Zip/Postal Code: Home Phone Number: Mobile Phone Number: Email Address: Birthday: Marital Status: Married

More information

Welcome to Medina Family Chiropractic and Acupuncture!

Welcome to Medina Family Chiropractic and Acupuncture! Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:

More information

Instructions for providing the required cadet physical and immunization forms.

Instructions for providing the required cadet physical and immunization forms. Instructions for providing the required cadet physical and immunization forms. May 2012 All Incoming Cadets and Parents All incoming resident students (cadets) for the Milledgeville campus are required

More information

VGCC VANCE-GRANVILLE COMMUNITY COLLEGE

VGCC VANCE-GRANVILLE COMMUNITY COLLEGE Student Medical Form VGCC VANCE-GRANVILLE COMMUNITY COLLEGE STUDENT MEDICAL FORM VANCE-GRANVILLE COMMUNITY COLLEGE INSTRUCTIONS FOR COMPLETING STUDENT MEDICAL FORM 1. Complete the four-page insert: Physical

More information

WELCOME TO THE MILLER CHIROPRACTIC CLINIC

WELCOME TO THE MILLER CHIROPRACTIC CLINIC WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following

More information

Florida Atlantic University Athlete Demographic

Florida Atlantic University Athlete Demographic Florida Atlantic University Athlete Demographic Please type or print in black ink. Please fill out the medical history completely. Do not leave blanks. Personal Information: : Sport: Name: Last Middle

More information

Program or Major Code: Current address: Blazer ID: Local Address: Permanent Address

Program or Major Code: Current  address: Blazer ID: Local Address: Permanent Address UAB Student Health and Wellness Health History Form Learning Resource Center 1714 9 th Avenue South, 3 rd Floor Birmingham, Alabama 35294-1270 (205) 934-3580 Please save this form and upload it to CertifiedProfile.com.

More information