Medical Information Sheet
Name:…………………………………………………………
Date
of
Birth: Day………..
Month……………. Year……………
Address:…………………………...…………………………….………………….
Postal
Code:……………
Telephone:
(…….)-…………………………..
Mother’s
Name:……………………....
Father’s Name: ……………………………
Business
Phone
Numbers: Mother:………..……….……… Father:.………..………………….
Alternate
emergency contact (if parents are not available):
Name:………………………………………………
Telephone:………………………
Address:……………………………………………………………………………………………..
Is
there any
information about the player’s family structure that would be important for the
staff to know (parents separated, divorced, custody issues, loss of family
member, etc.)? ………………………………………………………………………………………………………
Doctor:
………………………………….
Telephone:…………………………….
Dentist:………………………………….
Telephone:……………………………..
Date
of last
complete physical examination: …………………………………………
*Before a player participates
in a sports
program, any medical condition of injury problem should be checked by that
individual’s family physician.
Please circle the appropriate
response and
provide details below if you answer “Yes” to any of the questions.
Yes No
Previous
history of concussions
Yes No
Fainting
episodes during exercise
Yes No
Epileptic
Yes No
Wears
glasses
Yes
No
Are lenses
shatterproof
Yes No
Wears
contact lenses
Yes No
Wears
dental appliance
Yes
No
Hearing
problem
Yes No
Asthma
Yes No
Trouble
breathing during exercise
Yes
No
Heart
Condition
Yes
No
Diabetic: Type
1………….Type 2…………………
Yes No
Medication
Yes No
Allergies: Will
you be bringing an ANA Kit?
……….. EPI Pen?..................
Yes No Wears a
medical information bracelet or necklace.
For
what purpose? ……………………………………………………………….
Yes No
Has any
health problem that would interfere with participate on a Ringette team
Yes No Has had an
illness that lasted more than a week and required medical attention in
the past year
Yes No
Has had
injuries requiring medical attention in the past year
Yes
No
Has been
admitted to hospital in last year
Yes No
Surgery in
the last year
Yes
No
Presently
injured: Injured body
part:………………………………………...…….
Yes No
Vaccinations
up to date
Date of last Tetanus Shot………………..………..
Yes No
Hepatitis B
vaccination
Please give details
if you answered
“Yes” to any of the above. Use
separate sheet if necessary.
Medications:
……………………………………………………………………………………….
Allergies: Drugs,
Food, Environmental Insect Stings or Bites, Other (please describe)
……………………………………………………...……………………………………...………..
………………………………………………………………………………………………………
……………………...……………………………….………………………………………………
Medical
Conditions: ………………………………………………………………………………
Recent
injuries:…………………………………………………………………………………….
Any
information
not covered above:……………………………………………………………..
………………………………………………………………………………………………………
I understand that it
is my
responsibility to keep the team trainer advised of any change in the above
information as soon as possible.
In the event of a medical emergency and that no one
can be contacted,
team management will arrange to take my child to the hospital or a physician if
deemed necessary.
I hereby authorize the
physician and
nursing staff to undertake examination, investigation and necessary treatment
of my child.
I also authorize release
of information
of appropriate people (coach, physician) as deemed necessary.
Date:………………………Signature
of Parent or Guardian:……...…...………………………
Disclaimer:
Personal information used, disclosed, secured or
retained will be held
solely for the purposes for which it is collected and in accordance with the
National Privacy Principles contained in the Personal Information Protection
and Electronic Documents Act.
