Siena College Sports Medicine Health Questionaire

Please print all 3 pages of the form, fill out completely and fax to (518) 783-2992 or mail to:

 

Name: ________________________________________ SSN: ___________________ DOB: ____________ Sex:  M   or   F

Sport(s): _________________________________ Campus Address: _____________________________________________

Family Physician - Name, Address and Phone  ______________________________________________________________

_____________________________________________________________________________________________________

Emergency Contact - Name: _________________________________________  Relationship: ________________________

Home Phone (_______) ___________________________   Work Phone (_______) ___________________________

 

Do you consider yourself handicapped or disabled in any way?   Yes   or   No

If yes, please explain: __________________________________________________________________________________

_____________________________________________________________________________________________________

Have you ever been disqualified from sport participation for medical reasons?   Yes   or   No

If yes, please explain: __________________________________________________________________________________

_____________________________________________________________________________________________________

Are you allergic to any medications?   Yes   or   No

If yes, please list medications that you are allergic to: ________________________________________________________

_____________________________________________________________________________________________________

Are you currently taking any medications?   Yes   or   No

If yes, please list and explain why you are taking that medication: ______________________________________________

____________________________________________________________________________________________________

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