Mercy Acceleration – Registration and Health History First name: ________________________MI: ______Last name: _______________________________ Address: ______________________Rd Dr Ln Ave St Tr City:_____________ State:______ ZIP: __________ Gender: M or F School: ______________________________Grade _____ Date of birth:____________ Parent’s name(s): ________________________________________________ MHS partner: yes or no Home phone (
) ___________-___________ Cell phone (
)__________- ___________
E-mail address: _______________________________________________________________________ Health history It is very important that you provide accurate and complete information regarding your medical history and condition as training programs or procedures recommended will be based on such information. 1. Have you had any of the following: Bronchitis. ............................... _____ Asthma .................................... _____ Pneumonia ............................... _____ Wheezing with exercise .......... _____ Tuberculosis ............................ _____ Rheumatic fever ...................... _____ Diabetes ................................... _____ Reaction to latex...................... _____ Dizziness with exercise ........... _____
Hypertension (high blood pressure)….. _____ Hypotension (low blood pressure)…… _____ Heart attack…………………………..._____ Chest pain with exercise………………_____ Heart murmur…………………………_____ Erratic heart rate……………………… _____ Aneurysm…………………………….. _____ Seizure………………………………. _____ Stroke………………………………… _____
2. Please comment on any of the above checked: ____________________________________________ ___________________________________________________________________________________ 3. List any surgeries you have had: _______________________________________________________ ___________________________________________________________________________________ 4. List medications you take and reason: ___________________________________________________ ___________________________________________________________________________________ 5. Is there any other health or orthopaedic condition(s) that might limit your participation in Mercy Acceleration (e.g., bone or joint disability)? Explain: _________________________________________ ___________________________________________________________________________________ 6. Have you been advised by a physician to avoid any type of exercise? Explain: ___________________ ___________________________________________________________________________________ I have reviewed the above information and certify it to be true, correct and complete. Participant:______________________________________________ Date:______/______/______ Parent or guardian (if under 18):_____________________________ Date:______/______/______