HOCKEY CANADA MEDICAL FORM

Name

Day

Month

Year

Address

Postal Code

Home Number

Please enter a valid phone number.Format: (000) 000-0000.

Cell Number

Please enter a valid phone number.Format: (000) 000-0000.

Provincial Health Number

Parent/Guardian #1

Phone #

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian #2

Phone #

Please enter a valid phone number.Format: (000) 000-0000.

Alternate emergency contact (if parents are not available)

Name

Relationship to Player

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Doctor's Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Dentist's Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of last complete physical examination

Date

Medication - yes

Medication - No

Allergies - Yes

Allergies - No

Previous History of Concussions - Yes

Previous History of Concussions - No

Fainting - Yes

Fainting - No

Near Fainting - Yes

Near Fainting - No

Seizures and/or Epilepsy - Yes

Seizures and/or Epilepsy - No

Wears Glasses - Yes

Wears Glasses - No

Are lenses shatterproof - Yes

Are lenses shatterproof - No

Wears Contact Lenses - Yes

Wears Contact Lenses - No

Wears Dental Appliance - Yes

Wears Dental Appliance - No

Hearing Problem - Yes

Hearing Problem - No

Asthma - Yes

Asthma - No

Trouble Breathing during Exercize - Yes

Trouble Breathing during Exercize - No

Heart Condition - Yes

Heart Condition - No

Palpitations or Racing Heart - Yes

Palpitations or Racing Heart - No

Family History of heart disease - Yes

Family History of heart disease - No

Family History of unexpected death during physical activity - Yes

Family History of unexpected death during physical activity - No

Family History of Unexplained death of a young person - yes

Family History of Unexplained death of a young person - no

Diabetes - yes

Diabetes - No

Type 1

Type 2

Wears medical bracelet - Yes

Wears medical bracelet - no

Medical Bracelet purpose

Health problem that would interfere with participation on a hockey team - yes

Health problem that would interfere with participation on a hockey team - no

Illness that lasted longer than a week - yes

Illness that lasted longer than a week - no

Injuries requiring medical attention - yes

Injuries requiring medical attention - no

Been hospitalized in the last year - yes

Been hospitalized in the last year - no

Surgery in the last year - yes

Surgery in the last year - no

presently injured - yes

presently injured - no

Body Part Injured

Up to date on Vaccinations - yes

Up to date on Vaccinations - no

Hep B Vaccination - yes

Hep B Vaccination - no

Date of last Tetanus Shot

Please give details if you answered "Yes" to any of the above. (Use separate sheet if necessary)

Medications

Recent injuries

Allergies

Medical conditions

Any information not covered above

Date

Signature of Player

Date

Signature of Parent or Guardian

HOCKEY CANADA

MEDICAL INFORMATION SHEET