Mississauga Warriors Football Club

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Health Questionnaire

* Year of Birth:

* Player's First Name:

* Player's Last Name:

* Name of family's doctor:

* Are you currently in good health ?:

If "No", please explain.:

* Have you ever suffered a concussion?:

If "Yes", when did you suffer your last concussion ?:

If "Yes", were you treated by a physician ?:

If "Yes", what was the doctor's diagnosis and what did she/he recommend for treatment?:

Following your latest concussion, has your physician specifically approved your return to play football ?:

* Have you suffered any other serious injuries ?:

If "yes", please provide details:

* Do you suffer from asthma ?:

* Do you have any potentially life threatening allergies ?:

If "yes", please list your allergies:

Do you have any other health related issues that the coaching staff should know about ? If so, use this space:

It is imperative that all of the information above be truthful and accurate.
My signature below indicates that all of the input above is correct.
For players under the age of 18, this document must be signed by a parent or guardian.

Signature:

Date:

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Health Questionnaire