Union Dubuque F.C.
Our City. Our Union.

Health History Form

Please read and answer the following questions carefully. This form is to inform us of your health and medical history. Please select YES or NO. In the space provided, explain in detail, providing dates and medical care received for all YES answers. 
 

Name *
Name
Cell Phone *
Cell Phone
Date of Birth *
Date of Birth
Local Address *
Local Address
Home Address
Home Address
If Different
Emergency Contact Phone *
Emergency Contact Phone
Health History
Please read and answer the following questions carefully. This form is to inform us of your health and medical history. Please circle YES or NO, in the space provided, explain in detail providing dates and medical care received for all YES answers.
Surgery/Recovery History
Have you sustained any time-loss musculoskeletal injuries (e.g. sprain, strain, fracture, dislocation) to the following areas: *
Check all that apply
Have you experienced any of the following: *
Check all that apply
Please answer yes or no to the following statements:
Over the past two weeks, how often have you been bothered by the following feelings?
Have you ever received professional care, counseling, or treatment for the following? *
Select all that apply
I verify that all the above information is accurate and complete. I authorize Union Dubuque F.C. to release any and all medical records to appropriate medical consultants as deemed necessary by the Union Dubuque F.C. medical staff. Further, I do hereby give consent for treatment by the Union Dubuque F.C. medical staff, referring and consulting physicians, local hospitals, and other healthcare providers as referred to by the Union Dubuque F.C. medical staff. I understand that my records will be destroyed after 7 years, after the completion of my athletic participation.
Today's Date *
Today's Date
If under 18