Do you have diabetes or elevated blood sugar? YES NO. Is there a family history of heart disease? High blood pressure Diabetes. Obesity Lack of exercise …
UNCG collects this medical information to be aware of any potential medical
conditions that may arise during your participation in Team QUESt and to
facilitate efficient medical attention, as necessary The information on
this form is strictly confidential and may be protected by The Federal
Educational Rights and Privacy Act if participant is an enrolled UNCG
student
Name Date
Current
Address______________________________________________________________
Age_________________ Sex: Male / Female Height
_________Weight ____________
Health Insurance Company ______________________Policy
________________________
Home Telephone No Work Telephone No
In case of emergency contact: ________________________
Relationship ________________
Emergency contact phone
____________________________________________________
1 Please indicate if you are allergic to any of the following:
a Bee Sting YES NO If yes, how do you
react________________________
b Insect Bites YES NO If yes, how do you
react________________________
c Food YES NO
Please list foods
______________________________
d Poison Ivy YES NO If yes, how do you
react________________________
e Other Plants YES NO Please list plants
_____________________________
f Medications YES NO Please list
medications_________________________
What medication do you carry for allergic reactions?
______________________
2 Please list all medications you are currently taking and purpose:
_________________________________________________________________________
3 Are you currently suffering from any illness, injury or medical
condition that could affect your participation? YES or NO If yes,
please identify and explain: _______________
__________________________________________________________________________
4 If you have a disability, you may self-report to the Director of Team
QUESt, Marin Burton 334-4855 and request a reasonable accommodation
to participate Please make a request at least five 5 business days
before the event
5 Are you currently pregnant? YES or NO
6 Date of last tetanus shot:
_____________________
Please also complete the back of this form
7 Cardiac Risk Assessment Medical History: Circle yes or no for each of
the following:
a Do you have a history of heart disease or heart attack? YES NO
b Do you have a history of high blood pressure? YES NO
c Do you ever have chest pains or palpitations? YES NO
d Have you ever had exertional dizziness or fainted? YES NO
i If yes: Have you seen a doctor for these symptoms?
YES NO
ii Are they associated with shortness of breath? YES NO
iii Are they associated with sweating or anxiety? YES NO
e Have you ever had a stroke? YES NO
f Do you have diabetes or elevated blood sugar? YES NO
g Is there a family history of heart disease? YES NO
If you circled YES to any of the above, please explain below:
Issue: _____________________________________________________________
Explanation: _______________________________________________________
__________________________________________________________________
Issue: _____________________________________________________________
Explanation: _______________________________________________________
__________________________________________________________________
8 Are there any other physical, mental, or emotional problems and/or
concerns, temporary or permanent, diagnosed or not, that have not been
listed on this form that could affect your participation? YES
or NO If yes, explain: __________________________________
__________________________________________________________________________
___
I certify that this form is a complete and accurate statement of my health
I authorize The University of North Carolina at Greensboro UNCG to
obtain or provide emergency medical care I understand that I am solely
responsible for providing my own health insurance and for all medical
expenses related to my participation in Team QUESt programs If
participant is less than 18 years old, the undersigned parent or legal
guardian authorizes participation by minor, and acknowledges agreement and
acceptance to all terms
of this agreement
Signature of Participant or Parent/Legal Guardian Date
__________________________________________
Print Parent/Legal Guardian Name, if applicable
———————–
Summary of cardiac risk factors: For your information
Age: Male 45 Female 55 Smoking
Alcohol consumption 1 drink per day Family history of heart disease
High blood pressure Diabetes
Obesity Lack of exercise
———————–
Participant Medical Form
Source:ncat.edu
