Medical History Form

Last Name: _____________________ First Name: ________________________ MI: _______

Address: ___________________________________________________________________

City: ___________________________________ State: __________ Zip: ________________

Home Phone: _______________ Work Phone: ______________ Cell Phone: ______________

Birth Date: ___/___/___ Gender: ______________ Height: ___________ Weight: ___________

Emergency Contact's Name: ________________________ Phone: ______________________

• I rate my overall health status as: Poor_______ Fair______ Good______ Excellent_______

• I rate my current physical condition as: Poor_______ Fair______ Good______ Excellent_______

• List any allergies you have to medications, insect bites, foods, pollen, etc. and the reaction: _________________________________________________________________________________________

• List any medications taken including all current and recent prescriptions: _________________________________________________________________________________________

• List past surgical procedures, date, and type of procedure: _________________________________________________________________________________________

• List any chronic medical conditions currently suffered: _________________________________________________________________________________________

• List any health or medical conditions that may affect your participation in the registered activity: _________________________________________________________________________________________

• Write additional comments or any other pertinent information regarding your current health or medical history: __________________________________________________________________________________

Print Name: _________________________ Signature: ________________________ Date:________

If under 18, parent or legal guardian must sign below.

Print Name: _________________________ Signature: ________________________ Date:________

Signing for: _________________________