Vianney Hockey Athlete’s Medical History Form
(Please Print)

Name __________________________________________________ Date __________________

Address _______________________________________________________________________ 

Birth Date ________________

Telephone __________________________________________________ 

Social Security No. ____________________________

Who to Contact in case of any emergency if Parent is not Available?

Name _________________________________________________________ 

Relationship ____________________________________________________

Home Phone _____________________Work Phone ____________________

Car/Cell ______________Pager(s) ________________

Physician’s Name________________________________________________________________

Physician’s Telephone & Exchange Phone _____________________________________________

Please complete the following:

If the answer to any of the following questions is "Yes", please describe the problem and its implications for proper first aid treatment in the space provided.

Have you ever had (or do you presently have) any of the following:

Circle One Give Dates and Explanation

Head Injury (Concussion, Skull Fracture) Yes / No _____________________________

Fainting Spells Yes / No __________________________________________________

Convulsions/Epilepsy/Seizures Yes / No ______________________________________

Neck Injury Yes / No ____________________________________________________

Back Injury Yes / No ____________________________________________________

Asthma Yes / No _______________________________________________________

High Blood Pressure Yes / No _____________________________________________

Kidney Problems Yes / No _______________________________________________

Hernia Yes / No _______________________________________________________

Diabetes Yes / No _____________________________________________________

Heart Murmur Yes / No _________________________________________________

Allergies Yes / No _____________________________________________________

Specify Any Allergies:_________________________________________________

Injuries to:

Shoulder Yes / No ____________________________________
Knee Yes / No ______________________________________
Ankle Yes / No ______________________________________
Fingers Yes / No _____________________________________
Arm Yes / No _______________________________________
Other: Yes / No _____________________________________
Impaired Vision Yes / No ______________________________
Impaired Hearing Yes / No _____________________________
Other ___________________________________________________________________

When was the date of your last Tetanus Booster? _________________________________

Are you currently taking any Medications? __________ 

If yes, specify what and why __________________________________________________

________________________________________________________________________

Has your doctor placed any Restrictions on your activity? _______ 

If yes, explain _____________________________________________________________

Signed (Athlete)___________________________________________ Date ____________

Signed (Parent/Guardian) ____________________________________Date ____________