2008 CST Medical History Form

(please complete a form for each swimmer)

Swimmer’s name:

 

Emergency Contact Information:

 

         Name

     phone #

cell/work #

1.

  

 

 

2.

 

 

 

 

 

Please circle any of the following conditions that apply to your swimmer:

Heart.....Lung.......Kidney.....Liver.......Asthma......Hernia.....Concussion

Neck or Back injury.......Joint injury.......Seizures.......Diabetes......Other

 

Please explain in detail any conditions you circled:

 

 

 

 

Physician:

 

Allergies:

 

 

 

 

Regular medications:

 

 

 

 

 Parent’s signature________________________________________________

 

 

 

 

 

 

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