Phoenix Karate Inc. Medical Questionnaire

PHOENIX KARATE INC.

914 Burnhamthorpe Road West, 2nd Floor, Mississauga, ON, L5C 2S3 PhoenixKarateSensei@gmail.com ~ Phone/Text 289-962-9962 ~ PhoenixKarate.ca
Student Martial Arts Karate Participation Medical Questionnaire

THIS FORM MUST BE COMPLETED PRIOR TO PARTICIPATING IN ANY CLASSES OR EVENTS. Any and all information collected is kept confidential and will only be disclosed or relied upon in the event of a medical emergency or when first aid treatment is deemed necessary.
Student's Name:*

First NameLast Name
Student's Date of Birth (D.O.B.)*

DayMonthYear
Date
Student's Past and Present Health and Medical History (check all that apply)

Disease of the heart and arteriesAbnormal electocardiogram ECGHigh/Low Blood pressureAngina Pectoris (chest pain)EpilepsyStrokeAnemiaAbnormal Chest X-rayCancerAsthma or other lung disease or breathing issueOrthopedic or muscular-skeletal problemsDiabetesAllergiesAidsHepatitis A, B or CHistory of nosebleedsAny surgeries in the last 12 monthsExperiencing any chronic painAny concerns with ADHD, ADD, ASD or AutismWear a medical alert bracelet, necklace or otherAny current injuriesCurrently taking any medications or natural supplementsAny other prior or pre-existing health conditions
Please list and explain any items that have been checked off above. Also explain and indicate any recommendations your doctor has made regarding exercise:
Primary Emergency Contact Information:*

First NameLast Name
Primary Emergency Contact Phone Number:*
Please enter a valid phone number.
Relationship to Student:*
Secondary Emergency Contact Information:

First NameLast Name
Secondary Emergency Contact Phone Number:
Please enter a valid phone number.
Relationship to Student:
DECLARATION:*

I declare that I have read, understand and have completed this medical questionnaire form to the best of my knowledge. I acknowledge and agree that Phoenix Karate Inc will not be repsonsible for injuries that arise due to the non-disclosure of information in this questionnaire or pretinent and relevant information that ought to have been shared or disclosed. I understand and agree that I shall be required to keep Phoneix Karate Inc updated of any changes to the information provided on this medical questionnaire.
Name of Person Completing This Questionnaire:*

First NameLast Name
Signature of Person Completing This Questionnaire:

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Relationship to Student:*
Date*

DayMonthYear
Date
Hour MinutesAM/PM Option
Should be Empty:

PHOENIX KARATE INC.

Student Martial Arts Karate Participation Medical Questionnaire