Flag Football Bio Form Player Medical Questionnaire Name * Name First First Last Last 1. Since your last medical exam, have you had any injuries requiring medical attention? * Yes No Explain * 2. Since your last medical exam, have you had any illness lasting more than 5 days? * Yes No Explain * 3. Are you taking any medicine or under a physician's care at this time? * Yes No Explain * 4. Any feeling of faintness, dizziness, or fatigue, after heavy exertion? * Yes No Explain * 5. Do you wear glasses or contacts? * Yes No Explain * 6. Since your last medical exam, have you had surgical operation or fracture? * Yes No Explain * 7. Since last medical exam, have you been treated in a hospital or emergency room? * Yes No Explain * 8. Since last medical exam, have you been removed from participation in any sport? * Yes No Explain * 9. Any known allergies? * Yes No Explain * 10. Any chronic disease? * Yes No Explain * If you are human, leave this field blank. Submit
