Medical Form
To be completed for each athlete each year
Player Information
Rep Team Name
Year
*
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
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Gender Identity
*
Female
Male
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Cell Number
*
Health Card Number
*
Emergency Contact
Emergency Contact Name
*
Emergency Contact Relation to Player
*
Emergency Contact Email Address
*
example@example.com
Emergency Contact Cell Number
*
Medical History
Allergies or Any Dietary Restrictions (Title & Severity):
Chronic Conditions/Previous Illnesses:
Medications:
Inoculations:
Supplements:
Answer all of the following questions pertaining to the status of your health WITHIN THE LAST YEAR:
1. Has a doctor denied or restricted your participation in sport for any reason?
*
Yes
No
2. Have you been admitted to the hospital for any reason?
*
Yes
No
3-1. Have you had surgery?
*
Yes
No
3-2. Have you been cleared to participate fully in sports?
*
Yes
No
3-3. Please attach the clearance note below.
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4. Have you been advised to be on any medication on a regular basis?
*
Yes
No
5. Have you had a skin infection?
*
Yes
No
6. Have you had any injuries requiring you to miss more than one practice or game?
*
Yes
No
7. Have you had an injury that required treatment/therapy?
*
Yes
No
8. Do currently have an incompletely healed injury?
*
Yes
No
9-1. Have you had a concussion, or been hit causing confusion, headache, or memory loss?
*
Yes
No
9-2. If yes, how many and when?
10. Have you had a burner, stinger, neck injury?
*
Yes
No
11. Have you been tested for a blood-bourne pathogen? (i.e. HIV, Hep B/C)
*
Yes
No
12. Have you experienced coughing/wheezing with exercise?
*
Yes
No
13. Have you experienced frequent or severe headaches?
*
Yes
No
14. Have you got lightheaded, dizzy or felt more short of breath than expected during exercise?
*
Yes
No
15. Have you experienced heat exhaustion or heat stroke?
*
Yes
No
16. has a doctor ordered testing for your heart? (ECG, EKG, ultrasound, etc)
*
Yes
No
17. Have you experienced heart palpitations (heart feels like pounding or racing)
*
Yes
No
18. Have you experienced unexplained weight loss/gain?
*
Yes
No
19. Do you use any special equipment? (brace, pads, orthotics)
*
Yes
No
Injury Status
Current Injuries:
Do you have any present injuries? Receiving treatment? What is the treatment?
Previous Injuries:
List previous injuries such as separated shoulders, fractures, dislocations, ligament reconstructions, discs, etc...
Taping Requests:
Indicate Games or Practices
Concussions/Head Injuries:
History from past 2 years? When and how long were you concussed for?
Other Information:
Other useful information not asked above, other requests for supplies, do you wear glasses, contacts, dentures, etc.?
Consent/Certification
I consent to the release of all information contained in, or arising from this questionnaire to the appropriate members of the support staff of Saskatchewan Rugby and I certify that I have made a full and complete disclosure concerning any and all conditions, allergies, medications, injuries, and head injury information. I have answered completely and truthfully all questions.
Declaration
I hereby certify the above information is correct and factual
Date of Form Completion
*
-
Month
-
Day
Year
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