Medical Information and Authorization PARENT/GUARDIAN AUTHORIZATION AND RELEASE

PARTICIPANTNAME:___

SECTION 3. HEALTH HISTORY (Please check Yes or No)

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:

___ ___ ___ ___

Additional Information

Can the participant swim? ☐ Yes ☐ No Date of last tetanus shot: _____