Application Forms MedicalQuestionnaire FORM 1:Initial Form FORM 2:Student Questionnaire FORM 3:Parent Questionnaire FORM 4:Medical Questionnaire FORM 5:Physical Questionnaire "*" indicates required fields General InformationName* First Middle Last Date of Birth* MM slash DD slash YYYY Email* Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Emergency ContactName*Relationship to you*Phone*Additional Phone NumberAdditional Emergency Contact* Add an Additional Emergency Contact Name*Relationship to you*Phone*Additional Phone NumberInsurance InformationInsurance None Company*ID/Policy Number*Group Number*Rx BIN Number (6 digits)*Carrier's Employer*Phone*FaxAddress* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Father's Name* First Last Date of Birth* MM slash DD slash YYYY Mother's Name* First Last Date of Birth* MM slash DD slash YYYY Select all that you have experienced or are experiencing: Asthma (sudden, difficult breathing and wheezing) Blood transfusion(s) received Bronchitis (inflammation of the windpipe) Cancer Chronic ear infections Coma Diabetes Heart Problems Hepatitis Hypertension (high blood pressure) Meningitis Multiple sclerosis Mumps Penicillin allergies Peptic ulcer disease (ulcers caused by acid) Pneumonia (inflammation of the lungs) Polio Rheumatic fever Rubella (German Measles) Scarlet fever Seizures Sterilization Sexually transmitted disease Stroke Sulfa drug allergies Thyroid problems Tuberculosis (infectious disease of the respiratory system Varicose veins Asthma Past Present Blood transfusion(s)Bronchitis Past Present Cancer Past Present Chronic ear infections Past Present Coma Past Present Diabetes Past Present Heart Problems Past Present Hepatitis Past Present What kind?Date:Hypertension Past Present Meningitis Past Present Multiple sclerosis Past Present Mumps Past Present Penicillin allergies Past Present Peptic ulcer disease Past Present Pneumonia Past Present Polio Past Present Rheumatic fever Past Present Rubella Past Present Scarlet fever Past Present Seizures Past Present Sterilization Past Present Sexually transmitted disease Past Present List types and datesStroke Past Present Sulfa drug allergies Past Present Thyroid problems Past Present Tuberculosis Past Present Varicose veins Past Present Food Allergies or Dietary RestrictionsPlease list each allergy in its own row and indicate the level of severity (Hospitalization, Severe Reaction, Intolerance, Preference).Allergy/RestrictionLevel of Severity Add RemovePlease add any additional medical information that would be helpful for us to know.Select all that apply: You have had a medical illness or injury since your last checkup or sports physical You have an ongoing or chronic illness You have been hospitalized overnight You have taken any supplements or vitamins to help you gain or lose weight or to improve your performance You have had a rash or hives develop during or after exercise You have had racing of your heart or skipped heartbeats You have had high blood pressure or high cholesterol You have been told you have a heart murmur You have had any family member or relative die of heart problems or sudden death before age 50 You have had a severe heart infection You have family history of heart problems in close relatives younger than age 50 You have family history of Marfan's Syndrome A physician has denied or restricted your participation in sports for any heart problem You have had a severe viral infection You have current skin problems (e.g., itching, rashes, acne, warts, fungus, blisters) You have had a head injury or concussion You have been knocked out, become unconscious, or lost your memory You have frequent or severe headaches You have had numbness or tingling in your arms, hands, legs, or feet You have had a stinger, burner, or pinched nerve You have become ill from exercising in the heat You cough, wheeze, or have trouble breathing during or after an activity You use special protective or corrective equipment or devices that aren't usually used for your sport or position (e.g. knee brace, special neck roll, foot orthotics, retainer on your teeth, hearing aid) You have had problems with your eyes or vision You wear glasses, contacts, or protective eyewear You have had a sprain, strain, or swelling after injury You have broken or fractured any bones or dislocated any joints You have had knee surgery You have had back surgery You have had problems with pain or swelling in muscles, tendons, bones, or joints You want to weigh more or less than you do now You lose weight regularly to meet weight requirements for your sport You feel stressed out Please explain:ImmunizationsHepatitis A Hepatitis A Date of last shot MM slash DD slash YYYY Hepatitis B Hepatitis B Date of last shot MM slash DD slash YYYY Hib Hib Date of last shot MM slash DD slash YYYY MMR MMR Date of last shot MM slash DD slash YYYY Rubella Rubella Date of last shot MM slash DD slash YYYY Mumps Mumps Date of last shot MM slash DD slash YYYY Measles Measles Date of last shot MM slash DD slash YYYY Polio Polio Date of last shot MM slash DD slash YYYY Tetanus Tetanus Date of last shot MM slash DD slash YYYY Chicken Pox Chicken Pox Date of last shot MM slash DD slash YYYY Please list any other immunizations:ImmunizationDate of last shot Add RemovePlease list your current medications and what they are for:
