Sample Medical History Questionnaire Page 3
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1
2
3NO
YES
right or left? ________ Date(s) ________
26. Have you ever had knee surgery?
NO
YES
What was done and why? ___________________________________
Right or left? __________ Date(s) _________
27. Have you had a severe ankle sprain in the past two years?
NO
YES
28. Do you have a pin, screw, or plate in your body?
NO
YES
Where in your body? ____________________________________ Date(s) _____
29. Do you have any other conditions that we should be aware of (i.e., ulcers, pregnancy,
food or insect allergies, tendonitis, etc.)?
NO
YES
(Specify and give details)
__________________________________________
_________________________________________________________________________
30. Please give the dates of your last tetanus and polio shots:
Tetanus: ___________ Polio: ____________
The questions on this form have been answered completely and truthfully to the best of my
knowledge.
Signature of Athlete (or parent if athlete is a minor)
Date
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