ROCK BRIDGE WRESTLING

MEDICAL TREATMENT FORM

Wrestler's Name ________________________________________   Date of Birth ____________________

Parent/Guardian Name __________________________________    Relationship ____________________

Address _________________________________________________________________________________

Phones:  H - _____________________ W - _________________________ Cell - ______________________

Emergency Contact _________________________ Phone No. ____________________

Insurance Company _______________________________ Policy  No. _____________________________

Family Doctor  ___________________________________ Phone   No. _____________________________

Is your child presently on medication? ______ If yes, please list medication (s):  ____________________

Drug Sensitivities ________________________ Other Allergies _________________________

Any other Medical Information we should know about your wrestler? _____________________________

_______________________________________________________________________________________

Date of your child's last complete physical examination by a medical doctor ___________________

Please read the alternative statements below and sign under the one that you choose.  Sign only one!

1. If my child needs medical attention, it is my wish that I am contracted before any medical procedures

     are taken on my child, unless immediate treatment is necessary to save my child's life or to prevent

     permanent injury.

Parent/Guardian Signature _________________________      Date Signed ___________________________

2. If my child needs medical treatment while participating, it is my wish that the treatment is started

    while efforts are being made to contact me.  So that treatment is not delayed, I consent to any

    medical procedures that the physician believes are needed, on the understanding that efforts to

    contact me will continue to be made.  I accept responsibility for all costs related to such treatment.

Parent/Guardian Signature ___________________________  Date Signed __________________________

Name of Club ____________________________________________________________________________

USA Wrestling

MEDICAL HISTORY QUESTIONNAIRE

PLEASE PRINT IN CAPITAL LETTERS

Wrestler's Name___________________________________   USA Card No._____________

Emergency Contact_________________________________ Phone No.__________________

                      PLEASE CIRCLE THE CORRECT ANSWER, ALL INFORMATION WILL BE CONFIDENTIAL     

Yes No     1. Are you allergic to any general medication (aspirin, sulfa, penicillin, etc.)? If so        

                      please indicate what medication(s)____________________________________________

Yes  No     2. 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

 ___________________________________________________________________________________

Yes  No    3.   Have you ever had an epileptic seizure or been informed that you might have epilepsy?

Yes  No   4.  Have you ever been treated for diabetes? If so, please indicate the type(s) of

                     insulin or pills you use. __________________________________________________________________________________

Yes  No  5.  Has a medical doctor ever told you that you were anemic or had sickle cell anemia?

Yes  No  6.  Do you have or have you ever had high blood pressure? If so, list any medication for

                    it that you take regularly ____________________________________________________

Yes  No  7.  Do you have or have you ever had any of the following diseases? If so, please

  circle the appropriate ones.           Heart disease (rheumatic fever)    Liver disease (hepatitis)

                                                          Kidney disease (infections)          Lung disease(pneumonia)

Yes  No  8.  Have you ever been informed by a medical doctor that you have asthma? If so, what

                    medications, if any, do you take regularly ___________________________________

Yes  No  9.  Do you presently have an unrepaired hernia?

Yes  No 10. Have you ever been "knocked out" or experienced a concussion during the past 3

                    years? If so, give the dates of each ______________________________________

Yes  No 11. If the answer to No 10 is "yes" did the attending physician have you stay overnight

                    in a hospital? If yes, give the dates of each                                     

Yes  No 12. Have you ever had an injury to your neck involving nerves, vertebrae (bones),or

                    Discs that incapacitated you for a week or longer? If yes, give the dates of each

                    such injury.                                                       

.

Yes  No 13. Do you wear any dental appliance? If yes, circle the appropriate appliance:

                              Permanent bridge          Permanent crown or jacket

                     Braces Full plate          Removable partial plate

                     Permanent retainer          Removable retainer

Yes  No 14.  Do you wear contact lenses during competition?

Yes  No 15.  Have you had a fracture during the past 2 years? If yes, indicate which bone was broken and

                    the date it happened.__________________________________________________________

Yes  No 16.  Have you had a shoulder dislocation, separation or other shoulder injury in the past 2 years

                    That incapacitated you for a week or longer? If so, give the date of the injury.

                    _____________________________________________________________________________

Yes  No 17.  Have you ever had surgery to correct a shoulder condition? If so, give the dates and what was done.

                    _________________________________________________________________________________

                    _________________________________________________________________________________

Yes  No 18.  Have you ever had an injury to your back?

Yes  No 19.  Do you experience Pain in your back? If yes, indicate frequency:

                     Seldom               Occasionally          Frequently

            With vigorous exercise     With heavy lifting

Yes  No 20.  Have you injured your knee during the past 2 years with severe swelling as a result?

Yes  No 21.  Have you ever been told that you injured the ligaments and / or cartilage of either knee?

Yes  No 22.  Have you ever been advised to have surgery to correct a knee problem?

Yes  No 23.  If the answer to No. 22 is yes, has the surgery been completed? Date _______________

Yes  No 24.  Have you experienced a severe sprain of either ankle during the past 2 years?

Yes  No 25.  Have you had any injury to your foot or toes in the past 2 years. If yes, explain:

                      ________________________________________________________________________

Yes  No 26.  Do you have any chronic conditions that have not been mentioned above? If so, explain:

                     _______________________________________________________________________

The questions on both sides of this form have been answered completely and truthfully to the best of my knowledge.

Wrestler's Signature _________________________________________      Date _______________

Parent/ Guardian Signature__________________________________________________________