PLAYER INFORMATION SHEET

Name:

DOB:                                                                       Gender:

Address:                                                                  Weight:

City:                                                                         Height:

Postal Code:                                                            E-Mail:

Home Phone:

Business Phone:

Emergency Contact:

Health Card Number:

Family Doctor:

Address:

Phone Number:

Dentist:

Address:

Phone Number:

Current Medications:

Medication Allergies:

If so, do you wear a medical alert bracelet?

Food Allergies:

Other Allergies:

Previous Surgeries                                                             Date

Previous Concussions                                                         Date

Do you wear contacts or glasses?

If so, do you wear them for sports?

Athlete’s consent for treatment:

HEALTH HISTORY: Please check off appropriate boxes

Musculo-skeletal     r Headache        r TMJ/jaw r Neck r Back r Shoulder r Elbow r Wrist r Hip r Knee r Ankle r Feet r Tendonitis r Bursitis r Osteo/Rheumatoid Arthritis r Osteoporosis or bone disease r Degenerating discs r Scoliosis fnc/structural r Fractures/pins/plates r Concussions r Whiplash r Sprains/strains r Other Circulatory r High/low blood pressure r Heart disease r Blood clots r Varicose veins r Chronic congestive heart failure r Chest pain/ angina r Swelling legs/arms r Cold hands/feet r Heart attack/stroke

r Phlebitis r Pacemaker r Myocardial infarction Respiratory                                r Asthma / bronchitis r Emphysema r Shortness of breath r Chronic cough r Other Nervous system r Herpes / shingles r Chronic pain r Fatigue r Sleep disorder r CFS / fibromyalgia r Other Reproductive r Pregnant( trimester ___) r PMS r Gynecological conditions r Other Skin r Rashes r Warts r Athletes foot r Allergies r Other

Infectious Diseases r Hepatitis r Tuberculosis r HIV r Other Digestive r Constipation r Diverticulitis r Irritable bowel syndrome r Ulcers r Appetite changes r Diarrhea r Nausea / vomiting r Other Other r Cancer r Epilepsy r Hemophilia r Eating disorder r Depression r Drug / alcohol addiction r Nicotine / caffeine addiction r Diabetes r Vision loss r Hearing loss r Other