Please complete the confidential questionaire and indicate if you have had any of the following medical problems within the past 5 years. 

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Name Team List any prescription and non-prescription medicines you are currently taking: List allergies or reactions to medicines/foods/other agents: Are you currently under medical care for any reason? If yes, please explain: Please indicate whether you have had any of the following medical problems: High blood pressure Ulcers Alcoholism Anemia Asthma Kidney Disease High cholesterol Seizures/Epilepsy Heart disease Diabetes Tuberculosis Cancer Depression/Anxiety Diabetes, Type 1 or 2 Eczema Migraine headaches High blood pressure Glaucoma Any Additional Comments:

Thank you for your time.