Please print all 2 pages of the form, fill out completely and fax to (518) 783-2992 or mail to:
- Siena College Sports Medicine
UHY Center
515 Loudon Road
Loudonville, New York 12211-1462
Check all that apply: Please explain all in the section below.
| ___ Chicken Pox |
___ Back Problems |
___ Syncope with exercise |
| ___ German Measles |
___ Musculo-skeletal Disorders |
___ Kidney Infection |
| ___ Measles |
___ Neurological Disorders |
___ Kidney Stones |
| ___ Infectious Mononucleosis |
___ Seizures Disorders |
___ Chronic Kidney Disease |
| ___ Rheumatic Fever |
___ Fainting/Dizziness |
___ Sexually Transmitted Disease |
| ___ Scarlet Fever |
___ Head Injury w/LOC |
___ Blood in Urine |
| ___ Anemia |
___ Concussion |
___ Protein in Urine |
| ___ Bleeding Tendency |
___ Heart Conditions |
___ Sugar in Urine |
| ___ Changes in Appetite |
___ Marfan's Syndrome |
___ Pelvic/Vaginal Infection |
| ___ Changes in Weight |
___ Congenital |
___ Hernia |
| ___ Anorexia Nervosa |
___ Murmur |
___ Menstrual History |
| ___ Bulimia |
___ Rheumatic Heart |
___ Painful Periods |
| ___ Drug/Alcohol Abuse |
___ Disease |
___ Heavy Flow |
| ___ Steroid Use |
___ Palpitations |
___ Irregular Periods |
| ___ Constipation |
___ Other -- Specify _______________ |
___ Age of First Period |
| ___ Diarrhea |
___ High Blood Pressure |
___ Warts, Moles, Rashes |
| ___ Ulcerative Colitis |
___ Low Blood Pressure |
___ Eczema |
| ___ Irritable Bowl Syndrome |
___ Chest Pain |
___ Hives |
| ___ Crohn's Disease |
___ High Cholesterol |
___ Acne |
| ___ Stomach/Intestinal Problems |
___ Asthma |
___ Cancer -- Type ____________ |
| ___ Jaundice/Liver Disease |
___ Hay Fever |
___ Diabetes Mellitus |
| ___ Gall Bladder Trouble |
___ Pneumonia |
___ Hepatitis |
| ___ Pancreatitis |
___ Tuberculosis |
___ Recurrent Headaches |
| ___ Emotional Illness |
___ Bronchitis |
___ Migraine Headaches |
| ___ Depression |
___ Ear Infections |
___ Connective Tissue Disorders |
| ___ Insomnia |
___ Cystic Fibrosis |
___ Immune Deficiency Disorder |
| ___ panic/Anxiety Attack |
___ Sinusitis |
___ Gum or Tooth Disorders |
| ___ Joint Disease |
___ Bladder Infection |
___ Hearing Impairment |
| ___ Bone Fractures |
___ Shortness of Breath with exercise |
___ Speech Impediment |
| ___ Joint Injury |
___ Pregnancy |
___ Heat Related Illness |
| ___ Vision Problems |
___ Serious Accident/Injury |
___ Other: Explain Below |
Explanations: _________________________________________________________________________________________
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