USYouthSoccerOlympicDevelopmentProgram

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ODPMedicalHistoryQuestionnaire

NAME
LASTFIRSTMIDDLE

ADDRESS
STREETCITYSTATEZIP

DATE OF BIRTHEMERGENCY CONTACT PHONE ( ) -

PLEASECIRCLE"YES"OR"NO"ANDPROVIDEADDITIONALDETAILSWHEREREQUESTEDONBOTHSIDESOFTHISFORM.ALLINFORMATIONWILLBECONFIDENTIAL.

1.Areyouallergictoanymedication(aspirin,penicillin,sulfa,etc.)?NOYES
List:

2.Doyoutakeanyprescribedmedicationonapermanentorsemi-permanentbasis(steroids,birthcontrolNOYES
Pills,anti-inflammatories,antibiotics,etc.)? Listgivereason:

3.Haveyoueverhadanepilepticseizure?NOYES

4.Haveyoueverbeentoldbyadoctorthatyouhaveepilepsy? Listmedication: NOYES

5.Haveyoueverbeentreatedfordiabetes?NOYES

6.Haveyoueverbeentoldbyadoctorthatyouwereanemic?When?NOYES

7.Haveyoueverbeentoldbyadoctorthatyouhavesicklecellanemia?NOYES

8.Haveyoueverbeentoldbyadoctorthatyouhavesicklecelltrait?NOYES

9.Doyouhaveorhaveyoueverhadhighbloodpressure?Listmedication:NOYES

10.Doyouhaveorhaveyoueverhadthefollowingdiseases?

-Heartdisease(heartmurmur,rheumaticfever)Givedate: NOYES

-Lungdisease(pneumonia)Givedate: NOYES

-Kidneydisease(infections)Givedate: NOYES

-Liverdisease(mononucleosis,hepatitis)Givedate: NOYES

11.Doyouorhaveyoueverbeentoldbyadoctorthatyouhaveasthma? Listmedications: NOYES

12.Doyouorhaveyoueverhadaherniaor"rupture"? NO YESHasitbeenrepaired?NOYES

13.Haveyoubeen"knockedout"(unconscious)inthepast3years? Listdates: NOYES

14.Haveyouhadaconcussionorotherheadinjuryinthepast3years? Listdates: NOYES

15.Haveyoustayedovernightinahospitalduetoaheadinjury? Listdates: NOYES

16.Haveyoueverhadaneckinjuryinvolvingbones,nervesordiscsthatdisabledyouforaweekorlonger?NOYES
Typeofinjury Dates:

17.Doyouwearglassesorcontactsduringcompetition?NOYES

18.Doyouwearanyofthefollowingdentalappliances:(circlethosewhichapply)

PermanentBridge, Braces, RemovableRetainer, PermanentRetainer,
RemovablePartial Plate, FullPlate, PermanentCrownOrJacket?

19.Haveyouhadabrokenboneorfractureinthepast2years? R or LWhatbone? Dates: NOYES

20.Haveyouhadashoulderinjuryinthepast2yearsthatdisabledyouforaweekorlongerNOYES
(Dislocation,separation,etc.) RorL Typeofinjury: Dates:

21.Haveyoueverhadshouldersurgery?NOYES

R or L Whatwasdonewhy? Date:

22.Haveyoueverinjuredyourback?Typeofinjury: Date:NOYES

23.Doyouhavebackpain?(Circlethose,whichapply)NOYESSeldom, Occasionally, Frequently, WithVigorousExercise, WithHeavyLifting

24.Haveyouinjuredyourkneeinthepast2years? R or L Whatwasdonewhy? Date:NOYES

25.Haveyoubeentoldbyadoctororathletictrainerthatyouinjuredthecartilageinyourknee? R or LDateNOYES

26.Haveyoubeentoldbyadoctororathletictrainerthatyouinjuredtheligamentsinyourknee?R or LDateNOYES

27.Haveyoueverhadkneesurgery? R or L Whatwasdonewhy? Date:NOYES

28.Haveyouhadsevereanklespraininthepast2years?NOYES

29.Doyouhaveapin,screw,orplateinyourbody? Whereinyourbody? Date:NOYES

30.Doyouhaveanyotherconditionsthatweshouldbeawareof(i.e.ulcers,pregnancy,foodorinsectNOYESAllergies,tendonitis,etc.)? Specifygivedetails:

31.Pleasegivethedateofyourlastimmunizationfor:tetanuspoliomumpsrubellameasles Date:

THEQUESTIONSONTHISFORMHAVEBEENANSWEREDCOMPLETELYANDTRUTHFULLYTOTHEBESTOFMYKNOWLEDGE.

SignatureOfParent/GuardianDateSignatureOfPlayerDate