Medical History | Youth Wrestling

Wrestlers Name

Emergency Contact

USA Card No:

Phone No:

Are you allergic to any general medication (aspirin, sulfa, penicillin, ect.)? If so, please indicate what medication(s)

Are you now on any prescribed medication on a permanent or semi-permanent basis? If So, please indicate the name of the medication and why it was prescribed

Have you ever had an epileptic seizure or been informed that you might have epilepsy? If so, when?

Have you ever been treated for diabetes? If so, please indicate the type(s) of insulin or pills you use.

Has a medical doctor ever told you that you were anemic or had sickle cell anemia? If so, when?

Do you have or have you ever had high blood pressure? If so, list any medication for that you take regularly.

Do you have or have you ever had any of the following diseases? If so,list any medication for that you take regularly

Have you ever been informed by a medical doctor that you have asthma? If so, what medications, if any, do you take regularly?

Do you presently have any unrepaired hernia? If so, when did it start?

Have you ever been “knocked out” or experienced a concussion during the past 3 years? If so, give the dates of each

If the answer to above was “yes” did the attending physician have you stay overnight in a hospital? If yes, give the dates of each

Have you ever had an injury to your neck involving nerves, vertebrae (bones), or disca that incapacitated you for a week or longer? If yes, give the dates of each injury

Do you wear contact lenses during competition? If so, do you always need to?

Have you had a fracture during the past 2 years? If yes, indicate which bone was broken and the date it happened

Have you had a shoulder dislocatio, separation or other shoulder injury int he past 2 years that incapacitated you for a week or longer? If so, give the date of injury

Have you ever had shoulder surgery to correct a shoulder condition? If so, give the dates and what was done

Have you ever had an injury to your back? If so, when?

Have you injured your knee during the past 2 years with severe swelling as a result? If so, when?

Have you ever been told you injured the ligaments and/or cartilage of either knee? If so, when?

Have you ever been advised to have surgery to correct a knee problem? If so, when?

Have you ever experienced a severe sprain of either ankle during the past 2 years? If so, when?

Have you had any injury to your foot or toes in the past 2 years? If yes, explain

Do you have any chronic conditions that have net been mentioned above? If so, explain

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