Medical Information Form – electriccityspecialneedshockey

Player Name *

First

Last

Date *

Health Card Number *

Emergency Contact Name *

First

Last

Emergency Contact Number *

Medications *

Yes
No

Alergies *

Yes
No

Previous history of concussions *

Yes
No

Near fainting or brownouts *

Yes
No

Trouble breathing during exercise *

Yes
No

Palpitations or racing heart *

Yes
No

Fainting or seizures during or after physical activity *

Yes
No

Seizures and/or Epilepsy *

Yes
No

Asthma *

Yes
No

Downs Syndrome – test results from Atlanto-axial-dislocation: *

Heart Condition *

Yes
No

Family History of Heart Disease *

Yes
No

Family History of unexplained death during physical activity *

Yes
No

Family History of unexplained death of a young person *

Yes
No

Diabetes *

Yes
No
Type 1
Type 2

If diabetic *

Wears glucose monitoring sensor
Wears insulin pump
Does not apply

Wear glasses *

Yes
No

Are lenses shatter proof *

Yes
No
Does not apply

Wear Contact Lenses *

Yes
No

Hearing challenges *

Yes
No

Wears Medical Information bracelet/necklace – for what purpose? If yes, please add information below *

Yes
No

Medical Information bracelet/necklace information

Health problem that would interfere with participation on a hockey team *

Yes
No

Had an illness that lasted more than a week & required medical attention in the past year *

Yes
No

Been admitted to hospital in the last year *

Yes
No

Sugery in the past calendar year *

Yes
No

If currently injured please list details

Vaccinations up to date *

Yes
No

Date of last Tetanus shot

Hepatitis B Vaccination *

Yes
No

Please give details if you answered Yes to any of the above (use separate sheet if necessary):

Medications:

Allergies:

Recent Injuries:

Any information not covered above:

Medical Conditions:

I understand that it is my responsibility (as a player over 18, or the parent/guardian of a player under 18) to keep the team Trainer advised of any changes 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/myself 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/myself.

I also authorize the release of the information in this document, as well as treatment information to the appropriate people as deemed necessary (physician, medical staff, coach, team delegate).

Date *

Player Signature *

Signature of Parent or Guardian