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MEDICAL HISTORY _ PHYSICAL EXAMINATION GRAND PRAIRIE

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					                            MEDICAL HISTORY & PHYSICAL EXAMINATION
                             GRAND PRAIRIE AIRHOGS BASEBALL TEAM
                                               !
Name:                                               Date:

Social Security:                                    Date of Birth:

Current Local Address:




Local Telephone #:                                  Second #:

      Cell Phone #:                                  Pager #:

E-mail Address:

Spouse's Name (if married):

Permanent Address:




Home Telephone #:                                   Second #:

Nearest Relative's Name:                                        Relation:

Nearest Relative's Address:



Nearest Relative's Phone:

Who should we contact in case of an emergency?

Relation:                            Telephone #:

Address:
                                      GRAND PRAIRIE AIRHOGS
                                     PREVIOUS MEDICAL HISTORY
                                                 !
Name:                                                      Date:

                 Major Medical Problems:       1.
                 (include hospitalizations)
                                               2.

                                               3.

                                  Surgeries:   1.
                    (include include dates)
                                               2.

                                               3.

                                               4.

                                               5.


Allergies:


Medications (taken regularly):




                                               FAMILY HISTORY
                                                      !
FATHER (AGE):            (HEALTH STATUS):

              (If deceased, cause of death):

MOTHER (AGE):            (HEALTH STATUS):

              (If deceased, cause of death):

SIBLING (AGE):           (HEALTH STATUS):

              (If deceased, cause of death):

SIBLING (AGE):           (HEALTH STATUS):

              (If deceased, cause of death):
SIBLING (AGE):                 (HEALTH STATUS):

                  (If deceased, cause of death):

Have blood relatives had the following condition(s):
(please check as many as apply)

      Cancer                                    Convulsions                             Stroke
      Tuberculosis                              Seizures                                Death of Heart Disease before age 50
      Diabetes                                  Mental Illness                          Marfan's Syndrome
      Heart Trouble                             Excessive Bleeding                      Sickle Cell Disease/Trait
      High Blood Pressure                       Hereditary Defects



                                                   PREVIOUS INJURY HISTORY
                                                                        !
For all prior injuries please list to the best of your recollection what was injured, the date of the injury and how much time you missed.


HEAD (Concussions, Memory loss, Lacerations, etc.):




EYES, EARS, NOSE (Fractures, loss of hearing, altered vision, etc.):




NECK (Fracture, stinger, sprain, strain, pinched nerve, ruptured disc, etc.):




BACK (Strain, sprain, fracture, ruptured disc, pinched nerve, abnormal curve, etc.):




SHOULDER (AC joint sprain, rotator cuff strain, dislocation, subluxation, etc.):
ARM/ELBOW (Fracture, strain, sprain, tendonitis, dislocation, etc.):




HAND/FINGERS (Sprain, dislocation, fracture, bruise, etc.):




PELVIS/GROIN (Strain, hernias, contusions, hip pointer, dislocations, etc.):




THIGH (Quadriceps/Hamstring strains, contusions, fracture, etc.):




KNEE (Sprain, cartilage injuries, ligament injuries, tendonitis, patella injuries, etc.):




LOWER LEG (shin splints, fractures, achilles injuries, tendonitis, etc.):




ANKLE (Fractures, Sprains, Dislocations, etc.):




FOOT/ TOES (Fractures, turf toe, sprain, arch problems, foot conditions, etc.):
 OTHER INJURIES OR ILLNESS:




 ANY OTHER TIME LOST FROM PLAYING OR ANY OTHER REASONS:




                                 GRAND PRAIRIE AIRHOGS
                              HEALTH HISTORY QUESTIONNAIRE
                                            !
Name:                                                    Date:

CHILDHOOD DISEASES - HAVE YOU EVER HAD


          Measles                  Rheumatic Fever               Scarlet Fever
          German Measles           Whooping Cough                Other (please list)
          Mumps                    Chicken Pox

PRIOR IMMUNIZATIONS - ARE YOU VACCINATED AGAINST (if known):


          Tetanus                  Influenza                     Human Papilloma Virus - HPV
          Polio                    Swine Flu                     (venereal warts)
          Hepatitis A              MMR                           Varicella Zoster (chicken pox)
          Hepatitis B              Diptheria

ALLERGIES - ARE YOU ALLERGIC TO:


          Aspirin                  Hay Fever                     Tetanus
          Codeine                  Asthma                        Cosmetics
          Sulfa                    Grass                         Morphine
          Penicillin               Foods                         Medications (list below)
          Dust                     Anti-inflammatories           Other (please list)
DO YOU CURRENTLY HAVE, OR HAVE YOU EVER HAD:


   Abnormal pigment              Anemia                         Appendicitis                         Artificial eye
   Bladder infections            Blood disease                  Black stools                         Bleeding disorder
   Chest pain                    Chronic sinus infections       Cold hands/feet                      Cancer
   Concussion/knocked out        Constipation                   Colitis or bowel disease             Convulsions
   Diabetes                      Dizziness                      Dry skin                             Ear disease
   Eczema                        Epileptic attacks              Frequent boils                       Fainting spells
   Frequent headaches            Frequent cramping              Frequent diarrhea                    Frequent rashes
   Frequent nosebleeds           Frequent urination             Gall bladder trouble                 Frequent skin infections
   Glasses/Contacts              Gout                           Hearing aid                          Heart murmer
   Heat illness                  Heat cramps                    Hemorrhoids                          Hepatitis
   Hernia                        High Blood Pressure            Impaired hearing                     Jaundice
   Liver trouble                 Low Blood Pressure             Malaria                              Meningitits
   Mononucleosis                 Paralysis                      Psychiatric care                     Pneumonia
   Painful urination             Single paired organ            Skin disease                         Phlebitis
   Sickle Cell disease/trait     Vomiting blood                 Spitting up blood                    Tuberculosis
   Stomach or Peptic ulcer       Thyroid disease                Upper respiratory infections         Wheezing
   Asthma                        Blood in urine                 Chronic cough                        Dental bridges
   Black outs                    False teeth                    Frequent indigestion                 Glaucoma
   Eye disease                   Hives                          Kidney or Gall stones                Migraine headaches
   Heart trouble                 Sore throats                   Slow healing                         Shortness of breath
   Gonorrhea or Syphilis         Herpes                         Other sexually transmitted diseases


DO YOU CURRENTLY TAKE, OR HAVE YOU EVER TAKEN:


       Sedatives               Cholesterol medications          Tranquilizers                  Appetite suppressants
       Anti-inflammatory       Insulin                          Pain medication                Hormones
       Diet pills              Muscle relaxants                 Laxatives                      Blood pressure meds


       Other (please list)




  I do hereby certify that I have completed this questionnaire completely and correctly to the best of my
  ability and knowledge. I certify that there are no previous illnesses or injuries that I have incurred, other
  than those that I have listed on the preceding pages.      !        !       !       !       !      !       !


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                                  Certification of Corrections of Information

I certify that I have answered this questionnaire and all questions of the team physician completely and
correctly to the best of my knowledge. I certify that I have not had any prior illnesses or injuries other than
those I have listed on this questionnaire.

I further certify that the team physician has explained to me that playing professional baseball may result in
serious physical injury and in the aggravation, deterioration, or reinjury of any preexisting medical condition
(s) during and after my employment by the Grand Prairie AirHogs Baseball Team. I fully understand and
assume the possible consequences of playing professional baseball with the medical condition(s) set forth in
this questionnaire or discussed with the team physician.

                               Permission for Release of Medical Information

I, hereby authorize and empower the Grand Prairie AirHogs and its representatives to examine, copy and/or
obtain copies of any and all medical records relating to my health history, injury, complaints, tests, findings
and treatments, and I also hereby authorize all physicians, hospitals, clinics, schools, colleges/universities, and
all other amateur and professional teams or organizations and/or facilities that may possess such records, to
make them freely available to the Grand Prairie AirHogs representatives. I do hereby release and discharge all
such institutions and persons from any and all claims by reason thereof.

I understand that the team physician is a representative of the Grand Prairie AirHogs Baseball Team and that
he or she may therefore disclose any or all of the medical information contained in this questionnaire or my
medical files to the team. I further authorize the release to the team and its coaching staff, all medical and
surgical information gained by the team physician during the course of my employment.

I hereby authorize the team to release this questionnaire and any and all other information in my medical file
to any other team to which I am released, or traded, or to which my contract is assigned. I have received a
copy of regulations regarding disclosure of protected health information.


5If applicable) I have reviewed my medical summary that was updated on_________(date, month, year) and:!
!!

_____I certify that it is complete, accurate, and up-to-date. I have had no additional injury, illness, or surgery
performed.

_____Please make the following additions or corrections to update my medical summary:


Date:________________________ Player's Name (Printed):_________________________________________


Player's Signature:___________________________________________________________________________

Physician's Signature:________________________________________________________________________!

				
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