PGA MEDICAL HISTORY SURVEY

Does participant have any condition that would preclude or limit participation in our programs? NO YES

If yes, please explain: _______________________________________________________________________________

Has participant ever been informed that they have Asthma? NO YES

If so, is it controlled by medication? NO YES

Has participant ever been informed that they might have epilepsy, or ever experienced a seizure? NO YES

Has participant been treated for infectious mononucleosis, viral pneumonia, or another infectious

disease during the past twelve months? NO YES

Has participant ever been treated for or informed by a medical doctor that they have a heart problem,

a heart murmur, or high blood pressure? NO YES

Has participant ever been told they had hemophilia or other bleeding disorders

or currently have easy bleeding or bruising? NO YES

Has participant ever been told that they have a hernia? NO YES

If so, is it repaired? NO YES

Has participant had any operations in the past two years? NO YES

If yes, indicate the anatomical site and date: ___________________________________________________________

Is participant currently taking prescribed medications? NO YES

If so, indicate name of drug and indicated why it is prescribed: _____________________________________________

Has participant ever been treated for Osgood-Schlatter (knee) Disease? NO YES

Has participant had a fracture during the past two years? NO YES

If yes, indicate the site of the fracture and the date: _____________________________________________________

Has participant had any joint dislocation during the past two years? NO YES

If so, please indicate which joint: _____________________________________________________________________

Does participant ever experience pain in the back? NO YES

If yes, indicate frequency by circling the answer:

SELDOM OCCASSIONALLY FREQUENTLY ONLY ON VIGOROUS EXERCISE or HEAVY LIFTING

Is participant allergic to penicillin or any other medications? NO YES

If so, please list: _________________________________________________________________________________

Have there been any disciplinary, emotional, learning disabilities or other concerns, which we should be aware of?

If so, please explain: ______________________________________________________________________________

PARENT/GUARDIAN/ STUDENT: All of the above questions have been answered completely and truthfully to the best of our knowledge.

Date _____________________ Parent Signature ____________________________________________________

Date _____________________ Student (over 18) Signature ____________________________________________