Volunteer Participant Information

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Your Contact Information

About You

years old
Lbs.

General Health Information

Medications

Allergies

Check all that apply.
(Please give details of the symptoms checked above.)

Asthma and Bronchitis

Diseases and Conditions

Anemia Details

Hepatitis Details

Glasses or Contact LensEyes

Headache Details

Anxiety Details

Fitness

Head Trauma

Head Trauma Details

(Fell off bike, fell off horse, playing hockey, hit in the head with a baseball bat, car accident, etc.)
Seconds / Minutes / Longer
(For example, skull x-ray, CAT or MRI scan, EEG)
(Woken up every hour by parents, spouse, etc. during the night)
(Headaches, nausea, dizziness, seizures)
(For example, no sports for weeks / months)

Prior Hospitalizations and Surgeries

Administrative Information