University of the Cumberlands

Date:

UC ID #:

Sport:

Age:

Name:				DOB:
	Last	First	Middle

Last 4 digits of Social Security #:

Email:

Home Phone #:

Cell Phone #:

HAS ANY BLOOD RELATIVE EVER HAD – CHECK YES OR NO

GENERAL MEDICAL ALLERGIES – ARE YOU ALLERGIC TO – CHECK YES OR NO

MEDICAL PROBLEMS AND ILLNESSES – HAVE YOU EVER HAD – CHECK YES OR NO

FEMALES ONLY/MENSTRUAL HISTORY

	YES	NO
Have you ever had a stress fracture
Are you happy with your weight
What do you consider your ideal weight

Age at first period ( )

Last Period – Month/Year ( )

Longest time between periods ( )

HAVE YOU EVER HAD – CHECK YES OR NO

Have you ever had an operation or been hospitalized? YES NO

If YES:

Daily Medications:

Comments/Other Medical Information:

I do hereby state, to the best of my knowledge and belief, my answers are correct.

Athlete’s Signature: Date: