Medical Information and Authorization
PARENT/GUARDIAN AUTHORIZATION AND RELEASE
PARTICIPANTNAME:___
Hospitalized in the past? ☐ Yes ☐ No
Breathing issues during activity? ☐ Yes ☐ No
Surgery of any kind? ☐ Yes ☐ No
Use of medical equipment? ☐ Yes ☐ No
Currently taking medications? ☐ Yes ☐ No
Vision problems? □ Yes □ No
Allergies (medications, food, insects)? □ Yes □ No
Bone/joint injuries? ☐ Yes ☐ No
Fainted during exercise? ☐ Yes ☐ No
Missing paired organ? □ Yes □ No
Dizziness during or after exercise? □ Yes □ No
Asthma diagnosis? □ Yes □ No
Chest pain during or after exercise? □ Yes □ No
Use of inhaler? □ Yes □ No
High blood pressure? ☐ Yes ☐ No
Diabetes? □ Yes □ No
Heart murmur? □ Yes □ No
Use insulin? □ Yes □ No
Rapid heartbeat episodes? □ Yes □ No
Tobacco use? □ Yes □ No
Family history of heart problems before age 50?
Family history of sickle-cell anemia? □ Yes □ No
□ Yes □ No
Other medical problems? ☐ Yes ☐ No
Skin problems? ☐ Yes ☐ No
Injury in the last year? ☐ Yes ☐ No
Head injury? ☐ Yes ☐ No
Loss of consciousness? □ Yes □ No
Seizures or epilepsy? □ Yes □ No
Nerve injuries? □ Yes □ No
Heat-related illness? ☐ Yes ☐ No
Dizziness in heat? ☐ Yes ☐ No
Explain any “Yes” responses:
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Can the participant swim? ☐ Yes ☐ No
Date of last tetanus shot: _____