Medium

Available on

Apple Android Windows

Wrestling Medical History Questionnaire Mobile App

If you are traveling and one of your athletes needs medical attention, this information can be of great value to an attending physician. The parent's Medical Instruction and the Medical History Questionnaire for each athlete should be kept in a sealed envelope with the participant's name on the outside in or with the club's medical files. It is recommended that the kit also have a list of emergency phone numbers for each club member, along with the standard 911, police, ambulance, fire, etc., phone numbers.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Wrestling Medical History Questionnaire Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Wrestler's Name

  • Ico integer

    USA Card Number

  • Ico textbox

    Emergency Contact

  • Ico integer

    Phone Number

  • Ico statictext

    PLEASE SELECT THE CORRECT ANSWER, ALL INFORMATION WILL BE CONFIDENTIAL.

  • Ico dropdown

    Are you allergic to any general medication (aspirin, sulfa, penicillin, etc.

  • Ico multiline

    If yes, please indicate what medication(s):

  • Ico dropdown

    Are you now on any prescribed medication on a permanent or semi-permanent basis?

  • Ico multiline

    If yes, please indicate the name of the medication and why it was prescribed:

  • Ico dropdown

    Have you ever had an epileptic seizure or been informed that you might have epilepsy?

  • Ico dropdown

    Have you ever been treated for diabetes?

  • Ico multiline

    If yes, please indicate the type(s) of insulin or pills you use.

  • Ico dropdown

    Has a medical doctor ever told you that you were anemic or had sickle cell anemia?

  • Ico dropdown

    Do you have or have you ever had high blood pressure?

  • Ico multiline

    If yes, list any medication for it that you take regularly:

  • Ico dropdown

    Do you have or have you ever had any of the following diseases?

  • Ico dropdown

    Have you ever been informed by a medical doctor that you have asthma?

  • Ico multiline

    If so, what medications, if any, do you take regularly:

  • Ico dropdown

    Do you presently have an unrepaired hernia?

  • Ico dropdown

    Have you ever been "knocked out" or experienced a concussion during the past 3 years?

  • Ico multiline

    If yes, please give the dates:

  • Ico dropdown

    If the answer to No 10 is "Yes" did the attending physician have you stay overnight in a hospital?

  • Ico multiline

    If yes, give the dates of each:

  • Ico dropdown

    you for a week or longer?

  • Ico multiline

    If yes, give the dates of each such injury:

  • Ico dropdown

    Do you wear any dental appliance?

  • Ico statictext

    PLEASE SELECT THE CORRECT ANSWER, ALL INFORMATION WILL BE CONFIDENTIAL.

  • Ico dropdown

    Do you wear contact lenses during competition?

  • ...and More!

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