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CAROLINA BASEBALL CAMP2005 REQUIRED MEDICAL FORM

NAME ______________________________ AGE__________GRADE__________DATE OF BIRTH_________________

SCHOOL _________________________ SPORT ___________________PERSONAL PHYSICIAN__________________

ADDRESS____________________________________________________________________________________________

Street City State Zip

N CASE OF EMERGENCY CONTACT: NAME________________________RELATIONSHIP___________________

PHONE: (h)_________________(w)________________ (c)_____________________________________________________________________________________________________________________________

Explain YES Answers belowCircle questions you do not know answers to.

. Have you had an illness or injury in the past year? YES__NO__ Company Health Insurance Information:

. Have you ever been hospitalized overnight? YES__NO__ Company_______________________________________

. Have you ever had surgery? YES__NO__ Address________________________________________

. Are you currently taking any prescription or non- Policy #________________________________________

prescription (non-counter) medicines or using an inhaler? YES__NO__ In name of______________________________________

. Do you have any food allergies to food? YES__NO__ Send claim to___________________Phone#___________

. Do you have any allergies to medicines? YES__NO__

. Do you have any allergies to stinging insects? YES__NO__ Explain YES answers here:

. 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. 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__ _______________________________________________

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 examinatio

i. .Has a doctor ever denied or restricted your the past 12 months and has been cleared to partici

participation in sports for any heart problems? YES__NO__ in athletic activities without any restriction. This

. Do you have any current skin problems? YES__NO__ physical is on file at his high school or at our home

0. 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, munconscious or lost your memory? YES__NO__ answers to these questions are complete and corre 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)

1. Have you ever become ill from exercising in the heat? YES__NO__ ____________________________ Date_______________2. Do you cough, wheeze or have trouble breathing during

or after an activity? YES__NO__ List any medications, including strength, and reason fo

a. Do you have asthma? YES__NO__ taking:

b. Do you have seasonal allergies that require medical _______________________________________________attention? YES__NO__ _______________________________________________

3. Do you use any special protective or corrective equipment _______________________________________________devices that arent normally used for your sport of position _______________________________________________

(for example knee braces, special neck roll, foot _______________________________________________

orthotics, retainer on your teeth, hearing aid? YES__NO__ _______________________________________________

4. Have you had any problems with your eyes or vision? YES__NO__ _______________________________________________

a. Do you wear glasses, contacts or protective eyewear? YES__NO__ _______________________________________________

5. 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__ _______________________________________________

f 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_________________

8/7/2019 Medical Form- Carolina Baseball Camp

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houlder___ Finer___ Ankle___ Upper Arm___ Foot___ Hepatitus B_____________Chicken Pox______________