Transplant Football World Cup - Athlete Medical Form

Transplant Athlete Medical Form

Please note that your medical forms must be completed ONLINE here.

You MUST visit the Doctor-in-charge of your transplant follow-up in order to get your accurate medical data and ensure that your Doctor approves your participation in the Transplant Football World Cup (TFWC). Completion of these forms confirms that you have indeed visited your doctor to obtain this information.

Medical Forms must be completed by 26 July 2024.

The information on your medical forms will be reviewed prior to confirmation of your ability to compete. If the information is incomplete you will not be allowed to participate.

Before competing in the Transplant Football World Cup, it is expected that your general health and fitness are stable as judged by your transplant follow-up doctor. Your health is to be measured by the tests performed by your follow-up doctor and, if necessary, your follow-up cardiologist or sports doctor. You are responsible for maintaining your own training program, preferably in conjunction with a sporting advisor/coach.

You should adapt your training program to match your chosen sports. Football is considered a "high stress" level sport.
COMPETITOR DETAILS
Team Country*
Name*

First NameLast Name
Date of Birth: *

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemaleOther
Email*
example@example.com
Mobile (include international dialling code)*
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Number (include international dialling code)*
TRANSPLANT DETAILS
Date of transplant*

MonthDayYear
Type of Transplant*

Bone Marrow / Stem CellDouble LungHeartHeart / LungIntestineKidneyLiverSingle LungPancreasPancreas and KidneyPancreas Islet CellOther
FITNESS INFORMATION
*I certify that I take part in regular physical activity as follows:
Times per week:*
Minutes per session:*
I am training at a stress level of:*

LowMediumHigh
I take part in the following sports for leisure / competitively*
MEDICATION

*Please complete the table below:*

	Name of Medication	Dose	Frequency
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

MEDICAL INFORMATION

Please answer Yes or No to the following questions:*

	YES	NO
Are you pregnant
Are you on anticoagulants
Do you have diabetes melitus
Do you have ischaemic heart disease
Do you have epilepsy
Do you have asthma

If you have had a heart or lung operation - please provide details?
Please state any medication you are allergic to?
LABORATORY DATA
Results of all tests are required.

All results should be from tests performed after 01 March 2024.

*Please complete the table below

	Result	Unit of Measurement	Date of test
Creatinine / eGFR: (Glomerular Filtration Rate)
Haemoglobin
ALT - Liver Recipients ONLY
AST - Liver Recipients ONLY
Bilirubin - Liver Recipients ONLY
Alkaline Phosphatase - Liver Recipients ONLY
Blood sugar
HbA1c (if diabetic)

Hepatitis B (HBsAg)*

YesNo
RESULT of Hepatitis B (HBsAg)*

PositiveNegative
Hepatitis C (anti-HCV)*

YesNo
RESULT of Hepatitis C (anti-HCV)*

PositiveNegative
Cyclosporine Level (target)
Tacrolimus Level (target)
CARDIO-VASCULAR & RESPIRATORY STATUS
Baseline Blood Pressure: *
History of High Blood Pressure?*

YesNo

Pulmonary Function (HEART/LUNG, LUNG TRANSPLANT ONLY)

	Results
FEV1:
Vital Capacity:

CARDIAC STRESS TEST
A cardiac stress test is recommended for all recipients, especially those with a history of coronary artery disease or over the age of 50.

It may be recommended by your local physician in appropriate cases and if performed the results should be declared below.
Will you be completing a cardiac stress test?*

YesNo
If you selected NO - you are required to tick the box below acknowledging that you understand the risk of not performing the stress test, as suggested.

Yes I understand

Cardiac Stress Test Results:

	Results
Maximum Strength tolerated and duration:
Percentage of maximal theoretic frequency:
Reason for stopping test:
ECG – rhythm abnormality: YES / NO
Resting pulse and maximal:

** Upload a copy of your Cardiac Stress Test results below **
Upload Cardiac Stress Test Results:

Files allowed: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, wma, mpg, flv, avi, jpg, jpeg, png
Cancelof
For those with an abnormal stress test, please supply results of the most recent
coronary angiogram or cardiac isotopic scan and date.

*Please complete the table below:

	Procedure	Date	Results
1
2
3

Ejection fraction of left ventricle (EFLV) -Required for cardiac transplant recipients
Rhythm abnormalities
MEDICAL DOCTORS DETAILS
Medical Doctor Name*
Hospital / Institute*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number (include international dialling code)*
Email*
example@example.com
Date of consultation*

MonthDayYear
Date
I confirm that my medical doctor carried out an examination at the date of consultation indicated above, agreed I am fit to compete in my selected events, and provided me with all the medical information required in this document.*

YesNo
Data Storage and Participation in Clinical Research

Please note that all relevant GDPR requirements will be followed in the management of medical forms.
I agree that my data will be transferred to an online system for access and used by the Transplant Football World Cup 2024 medical / physio team for the sole purpose of providing treatment, if required, for the duration of the Games.*

Yes
I am willing to be approached to participate in clinical research during the Transplant Football World Cup 2024?*

YesNo
I agree that after the Transplant Football World Cup my data may be stored in a non-identifiable format and may be used for future studies by the World Transplant Games Federation authorised researchers?*

YesNo
DECLARATION

I confirm that the information provided is true and accurate to the best of my knowledge and, where required, information is provided by a qualified medical doctor.
Electronic Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

COMPETITOR DETAILS

TRANSPLANT DETAILS

FITNESS INFORMATION

MEDICATION

MEDICAL INFORMATION

LABORATORY DATA

CARDIO-VASCULAR & RESPIRATORY STATUS

CARDIAC STRESS TEST

MEDICAL DOCTORS DETAILS

Data Storage and Participation in Clinical Research

DECLARATION