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Sample Medical Form:
MEDICAL HISTORY
FORM
NAME __________________________________________
SEASON OF PLAY _____________________ DATE OF BIRTH ______________
SOCIAL SECURITY NUMBER _____________________________ AGE ____________
LOCAL PHONE NUMBER ____________________
INSURANCE (Company, Policy Number, Employee's Name, Phone Number,
Address) ______________________________________________
_____________________________________________________________________________________________________________________
EMERGENCY CONTACT NAME AND PHONE NUMBER __________________________________________________________________
1. Are you taking any medication or supplements at the present
time? yes ___ no ___ comments________________________
Name of medication ________________________ Purpose
of medication _____________________________________________________
2. Do you wear glasses _________________ contacts ____________________
near/far sighted ______________________________________
3. Have you ever had a surgical operation yes ___ no
___ comments _______________________
4. Have you ever been weak or ill when exposed to high temperatures?
yes ___ no ___ comments _______________________
5. Do you have a loss or serious impairment of any paired organ?
yes ___ no ___ comments _______________________
6. Do you have, or have you had, any of the following. Please
provide comments if you answer yes to any question.
frequent headaches or dizziness comments _______________________________
asthma or allergies (if yes, do you use an inhaler).comments
_______________________________
diabetes .comments _______________________________
heart disease or heart murmurs .comments _______________________________
high blood pressure (above 139/90)...comments _______________________________
stroke .comments _______________________________
chest pain with exertion .comments _______________________________
epilepsy or convulsions .comments _______________________________
abnormal bleeding tendencies comments _______________________________
kidney disease comments _______________________________
ulcers, intestinal trouble, stomach pain .comments _______________________________
7. Have you ever been knocked out? If so, how many times?
.comments ______________________________
Were you evaluated by a doctor? Were you hospitalized?
comments ______________________________
8. Please provide information about any injuries you have had
to the following body parts:
back ______________________________________________________________________________________________________________
shoulder __________________________________________________________________________________________________________
arm, elbow, wrist or hand________________________________________________________________________________________________
hip or pelvis _______________________________________________________________________________________________________
leg or knee ________________________________________________________________________________________________________
ribs or chest ________________________________________________________________________________________________________
face or neck ________________________________________________________________________________________________________
ankle or foot _______________________________________________________________________________________________________
9. If you have been under a physician care now, or in the past,
have you been cleared to participate fully in polo (no medical
restrictions or
precautions? _____________________________
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