CAROLINA BASEBALL CAMP

2005 REQUIRED MEDICAL FORM

NAME ______________________________ AGE__________GRADE__________DATE OF BIRTH____________________

SCHOOL _________________________ SPORT ___________________PERSONAL PHYSICIAN_____________________
ADDRESS_______________________________________________________________________________________________
Street City State Zip
IN CASE OF EMERGENCY CONTACT: NAME________________________RELATIONSHIP______________________
PHONE: (h)_________________(w)________________ (c) __________________
___________________________________________________________________________________________________________________
Explain “YES” Answers below
Circle questions you do not know answers to.
1. Have you had an illness or injury in the past year? YES__NO__ Company Health Insurance Information:
2. Have you ever been hospitalized overnight? YES__NO__ Company__________________________________________
3. Have you ever had surgery? YES__NO__ Address___________________________________________
4. Are you currently taking any prescription or non- Policy #___________________________________________
prescription (non-counter) medicines or using an inhaler? YES__NO__ In name of_________________________________________
5. Do you have any food allergies to food? YES__NO__ Send claim to___________________Phone#______________
6. Do you have any allergies to medicines? YES__NO__
7. Do you have any allergies to stinging insects? YES__NO__ Explain ‘YES’ answers here:
8. Have you ever passed out during exercise? YES__NO__ __________________________________________________
a. Have you ever been dizzy during or after exercise? YES__NO__ __________________________________________________
b. Have you ever had chest pain during exercise? YES__NO__ __________________________________________________
c c. Do you tire more quickly than others during exercise? YES__NO__ __________________________________________________
d. Have you ever had a racing heart or felt your heart __________________________________________________
skip a beat? YES__NO__ __________________________________________________
e. Do you have high blood pressure or cholesterol? YES__NO__ __________________________________________________
d f. Have you ever been told you have a heart murmur YES__ NO__ __________________________________________________
g. Has any family member died of heart problems __________________________________________________
or sudden death prior to age 50? YES__ N0__ __________________________________________________
h. Have you had a severe viral infection within the past
month? YES__NO__ ___ I attest that my son has had a physical examination in
i. .Has a doctor ever denied or restricted your the past 12 months and has been cleared to participate
participation in sports for any heart problems? YES__NO__ in athletic activities without any restriction. This
9. Do you have any current skin problems? YES__NO__ physical is on file at his high school or at our home.
10. Have you ever had a head injury or concussion? YES__NO__
a. Have you ever been knocked out, becomes ___ I hereby state that, to the best of my knowledge, my
unconscious or lost your memory? YES__NO__ answers to these questions are complete and correct.
b. Have you ever had a seizure? YES__NO__
c. Do you have frequent or severe headaches? YES__NO__ SIGNATURE OF PARENT/GUARDIAN
d. Have you ever had numbness or tingling in ____________________________ Date__________________
your arms, hands, legs or feet? YES__NO__
e. Have you ever had a stinger, burner, or pinched nerve? YES__NO__ SIGNATURE OF ATHLETE (CAMPER)
11. Have you ever become ill from exercising in the heat? YES__NO__ ____________________________ Date__________________
12. Do you cough, wheeze or have trouble breathing during
or after an activity? YES__NO__ List any medications, including strength, and reason for
a. Do you have asthma? YES__NO__ taking:
b. Do you have seasonal allergies that require medical __________________________________________________
attention? YES__NO__ __________________________________________________
13. Do you use any special protective or corrective equipment __________________________________________________
devices that aren’t normally used for your sport of position __________________________________________________
(for example knee braces, special neck roll, foot __________________________________________________
orthotics, retainer on your teeth, hearing aid? YES__NO__ __________________________________________________
14. Have you had any problems with your eyes or vision? YES__NO__ __________________________________________________
a. Do you wear glasses, contacts or protective eyewear? YES__NO__ __________________________________________________
15. Have you ever had a sprain, strain, or swelling after YES__NO__ __________________________________________________
injury? __________________________________________________
a. Have you had any other problems with pain or swelling __________________________________________________
in your muscles, tendons, bones or joints? YES__NO__ __________________________________________________
If yes, check appropriate box and explain below:
Head___ Elbow___ Hip___ Neck___ Forearm___ Thigh___ Record the dates of your most recent immunization for:
Back___ Wrist___ Knee___ Chest___ Hand___ Shin/calf___ Tetanus________________ Measles_________________
Shoulder___ Finer___ Ankle___ Upper Arm___ Foot___ Hepatitus B_____________Chicken Pox______________