Client Health QuestionnaireAll information received on this form will be treated as strictly confidential. Please fill out completely and accurately. This information is essential to helping us develop a program that addresses your child’s goals and interests and is safe and effective.Medical Conditions Asthma Fainting Spells History of Head Injuries Rheumatic Fever Chronic Nosebleed Feet or Leg problems Migraine Seizures Diabetes Hemophilia/Bleeding disorders Rash Sleepwalking Digestive upsets Heart problems Recent illness or operation Urinary infections Ear, Nose, Throat infections Hernia Dislocated shoulder; swollen, painful joints; ‘trick or lock’ knee or other joint disability OtherPlease indicate any significant medical conditions, physical limitations, or any other concerns that might affect your child’s/ward’s full participation in Running4YourLife training.Please specify:Give details of usual treatment for each of the above conditions indicated:Please explain if your child/ward has any medical condition that requires any modification of his/her program.Allergies/AsthmaPlease list all known confirmed allergies to the following:Foods:Leave blank if N/AIf foods are life-threatening, please explain the symptoms and the treatment:Medications:Leave blank if N/AOther (e.g., bee or wasp stings, environmental allergies):Leave blank if N/AHas your child/ward suffered any serious allergic or asthmatic reaction? Yes NoPlease provide details, including the type and severity of reaction:Is allergy considered Mild Moderate Serious Life-ThreateningHas a doctor prescribed an Epi-Pen for your child/ward? Yes NoHas a doctor prescribed an inhaler for asthma? (Prescribed asthma inhalers must be carried by the child during training.) Yes NoHas a doctor prescribed an inhaler for any other reason? Yes NoDietary Restrictions Please list any foods your child/ward should not eat for medical, dietary, or religious reasons:MedicationDoes your child/ward take prescribed medication on a regular basis? Please specify:Leave blank if N/AWhat prescribed medication(s) should your child/ward have with him/her during training?Leave blank if N/AGeneral Does your child/ward wear or carry medical alert identification (e.g., bracelet)? Yes NoIf yes, please specify what is written on it:Does your child/ward have any other relevant medical condition that will require modification of the program? Yes NoIf yes, please explain:Should it become necessary for my child/ward to have medical care, I hereby give the coach permission to use her/his best judgment in obtaining the best of such service for my child/ward. I also understand that in the event of such illness or accident, I will be notified as soon as possible.Athlete NameDate of Birth MM slash DD slash YYYY Physician’s NamePhysician’s PhoneSignature
