Appendix A PLAQUEMINES PARISH RECREATION DEPARTMENT
2009 BIDDY BASKETBALL LEAGUE
MEDICAL HISTORY FORM
Name: ___________________________________ ___________________________ Date: ______/______/______
YES NO YES NO
___ ___ Allergies, hay fever, asthma ___ ___ Major or chronic illness
___ ___ Anemia or blood disease ___ ___ Malaria or other tropical disease
___ ___ Arthritis, backache or joint pain ___ ___ Motion sickness/disorders
___ ___ Broken bones, joint injuries ___ ___ Muscle disease or problems
___ ___ Cancer or other tumor ___ ___ Nervous breakdown or mental illness
___ ___ Stomach, gall bladder, intestinal trouble ___ ___ Painful, frequent or bloody urine
___ ___ Stomach, gall bladder, intestinal trouble ___ ___ Pneumonia or pleurisy
___ ___ Deafness or other ear troubles ___ ___ Recent weigh loss or gain
___ ___ Diabetes or thyroid disease ___ ___ Chest pain or angina
___ ___ Dizziness or fainting spells ___ ___ Sinus trouble or frequent sore throat
___ ___ Epilepsy or seizures ___ ___ Skin disease or rash, hives, eczema
___ ___ Shortness of breath ___ ___ Eye trouble, contact lens or glasses
___ ___ Frequent colds or persistent coughs ___ ___ Sugar or albumin in urine
___ ___ Frequent or severe headaches, or migraines ___ ___ Tuberculosis or chest disease
___ ___ Heart disease or heart murmur ___ ___ Ulcer or black stool
___ ___ Hemorrhoids or rectal bleeding ___ ___ Urinary tract infection
___ ___ Hepatitis or jaundice (liver trouble) ___ ___ Varicose veins or swelling of ankles
___ ___ Hernia or rupture ___ ___ Venereal disease; gonorrhea , syphilis, etc.
___ ___ High blood pressure ___ ___ Weakness or fatigue
___ ___ Kidney or bladder trouble ___ ___ Rheumatic fever
Have you ever suffered injury or disease to: Indicate if you ever had any back problems:
YES NO YES NO
___ ___ Back, head, or eyes? ___ ___ Back pain or back strain
___ ___ Heart, lungs, kidneys, or intestines? ___ ___ Back injury
___ ___ Spine, bones, or joints? ___ ___ Treatment for back pain
___ ___ Mouth, teeth, nose, or limbs? ___ ___ Disc removed or ruptured disc
Please make note of any other medical conditions on back!!
Name: _____________________________________________ __________________
Please make notation of any other medical conditions, surgery, or learning disabilities that your child may have:
_____________________________________________________________________________________________
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List all medications (even over the counter) that you child is taking:
_____________________________________________________________________________________________
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I hereby certify that the above information is true, accurate and complete to the best of my
knowledge, and that falsification of the information requested is grounds for discipline up to
and including suspension or termination from team.
PRINT NAME: __________________________________
SIGNATURE:___________________________________ DATE: ______/______/______