HOCKEY CANADA
MEDICAL INFORMATION SHEET
Name
DAY
Month
Year
Address
Postal Code
Phone Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Provincial Health Number (optional)
Parent/Guardian #1
Business #
Please enter a valid phone number.
Parent/Guardian #2
Business #
Please enter a valid phone number.
Alternate emergency contact (if parents are not available)
Name
Relationship to Player
Phone Number
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Doctor's Name
Phone Number
Please enter a valid phone number.
Dentist's Name
Phone Number
Please enter a valid phone number.
Date of last complete physical examination
/
Month
/
Day
Year
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
/
Month
/
Day
Year
Date
Signature of Player
Date
/
Month
/
Day
Year
Date
Signature of Parent or Guardian
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