Player Medical Questionnaire

Player Medical Questionnaire
Name
Name
First
Last
1. Since your last medical exam, have you had any injuries requiring medical attention?
2. Since your last medical exam, have you had any illness lasting more than 5 days?
3. Are you taking any medicine or under a physician’s care at this time?
4. Any feeling of faintness, dizziness, or fatigue, after heavy exertion?
5. Do you wear glasses or contacts?
6. Since your last medical exam, have you had surgical operation or fracture?
7. Since last medical exam, have you been treated in a hospital or emergency room?
8. Since last medical exam, have you been removed from participation in any sport?
9. Any known allergies?
10. Any chronic disease?