United States | Special Olympics Medical Form

Athlete Registration

* indicates required

State Program ^*

Local Area/Delegation ^*

Are you a new athlete to Special Olympics or re-registering?

New Athlete

Re-Registering

Athlete Information

First Name ^*

Middle Name

Last Name ^*

Preferred Name

Date of Birth ^*

Address (Street) ^*

City ^*

State ^*

Zip Code ^*

Phone

Email Address ^*

Gender ^*

Male

Female

Other

If other gender, please list:

Race/Ethnicity ^*

If Hispanic or Latino, please specify origin group:

Language (select all that apply)

English

Spanish

Other

Please list:

Athlete Employer (optional)

Does the athlete have the capacity to consent to medical treatment on his or her own behalf? (e.g. is the athlete their own guardian) ^*

Yes

Parent & Guardian

Required if minor or otherwise has a legal guardian.

Name

Relationship

Same contact information as athlete?

Yes

Address (Street)

City

State

Zip Code

Phone

Email Address

Emergency and Medical Contacts

* indicates required

Is emergency contact same as parent or guardian?

Yes

Emergency Contact Name ^*

Emergency Contact Phone ^*

Emergency Contact Relationship to Athlete ^*

Physician Name

Physician Phone

Insurance Company

Insurance Policy Number

Insurance Group Number

Sport Interest

* indicates required

Select any sport(s) that the athlete wishes to play: ^*

Add Another Sport

Please list any other sports that may not have been included above.

Has a doctor ever limited the athlete's participation in sports? ^*

Yes

If yes, please describe:

Current Health Status

* indicates required

Does the athlete have:

Autism

Down syndrome

Fragile X Syndrome

Cerebral Palsy

Fetal Alcohol Syndrome

Other Syndrome

Please specify:

Allergies & Dietary Restrictions

Is the athlete allergic to any of the following:

No Known Allergies

Latex ^*

Yes

Medications ^*

Yes

If yes, please specify:

Insect Bites or Stings ^*

Yes

If yes, please specify:

Food ^*

Yes

If yes, please specify:

List any special dietary needs:

Assisted Devices

Does the athlete use: (select all that apply)

Brace

Colostomy

Communication Device

C-PAP Machine

Crutches or Walker

Dentures

Glasses or Contracts

G-Tube or J-Tube

Hearing Aid

Implanted Device

Inhaler

Pacemaker

Removable Prosthetics

Splint

Wheelchair

Surgeries, Infections, Vaccines

List all past surgeries:

Does the athlete currently have any chronic or acute infections? ^*

Yes

If yes, please describe:

Has the athlete ever had an abnormal Electrocardiogram (EKG) or Echocardiogram (Echo)? ^*

Yes, had abnormal EKG

Yes, had abnormal Echo

If yes, please describe:

Has the athlete had a Tetanus vaccine in the past 7 years?

Yes

Epilepsy and/or Seizure History

Has the athlete ever been diagnosed with or experienced:

Epilepsy or any other type of seizure disorder ^*

Yes

If yes, had seizure during the past year?

Yes

If yes, list seizure type

Mental Health

Has the athlete been diagnosed with or experienced:

Self-Injurious behavior during the past year? ^*

Yes

Aggressive behavior during the past year? ^*

Yes

Depression (diagnosed) ^*

Yes

Anxiety (diagnosed) ^*

Yes

Describe any additional mental health concerns:

Family Health History

* indicates required

Has any relative died of a heart problem before of age 50?

Yes

Has any family member or relative died while exercising?

Yes

List all medical conditions that run in the athlete's family:

Past Diagnosis

* indicates required

Has the athlete ever been diagnosed with or experienced any of the following conditions:

Loss of Consciousness ^*

Yes

Dizziness during or after exercise ^*

Yes

Headache during or after exercise ^*

Yes

Chest Pain during or after exercise ^*

Yes

Shortness of breath during or after exercise ^*

Yes

Irregular, racing or skipped heart beats ^*

Yes

Congenital Heart Defect ^*

Yes

Heart Attack ^*

Yes

Cardiomyopathy ^*

Yes

Heart Valve Disease ^*

Yes

Heart Murmur ^*

Yes

Endocarditis ^*

Yes

High Blood Pressure ^*

Yes

High Cholesterol ^*

Yes

Vision Impairment ^*

Yes

Hearing Impairment ^*

Yes

Enlarged Spleen ^*

Yes

Single Kidney ^*

Yes

Osteoporosis ^*

Yes

Osteopenia ^*

Yes

Sickle Cell Disease ^*

Yes

Sickle Cell Trait ^*

Yes

Easy Bleeding ^*

Yes

Stroke/TIA ^*

Yes

Concussions ^*

Yes

Asthma ^*

Yes

Diabetes ^*

Yes

Hepatitis ^*

Yes

Urinary Discomfort ^*

Yes

Spina Bifida ^*

Yes

Arthritis ^*

Yes

Heat Illness ^*

Yes

Broken Bones ^*

Yes

Dislocated Joints ^*

Yes

Describe any past broken bones or dislocated joints if selected yes above

List any other ongoing or past medical conditions

If female athlete, list date of last menstrual period:

Neurological Symptoms

* indicates required

Has the athlete ever been diagnosed with or experienced any of the following conditions:

Difficulty controlling bowels or bladder ^*

Yes