Salisbury Sabres Football Medical Form
Personal Information to be filled out by parent/legal guardian PRIOR to Spring Camp
Player Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address, City, Postal Code
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Cell Phone
*
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact
*
Relationship (mother, father, aunt)
*
Emergency Contact Cell Phone
*
Format: (000) 000-0000.
Physician
Physician Address
Physician Phone Number
Format: (000) 000-0000.
Date of Last Physical
*
-
Month
-
Day
Year
Date
Alberta Health Care Number
*
Please "check" if the player is currently or has ever experienced any of the following:
Medical Conditions
Heat Stroke
Infectious Mononucleosis
Scarlett or Rheumatic Fever
Tonsillitis/ Sinusitis
Cough up Blood
Asthma
Sever Tooth or Gum Troubles
Stomach Ulcers
Pneumonia or Tuberculosis
Anemia or Low Iron
Hepatitis or Liver Trouble
Hernia or Rupture
Piles or Hemorrhoids
Irregular Heart Beat
High or Low Blood Pressure
Heart Murmur
Ear or Hearing Trouble
Difficulty with Vision
Frequent or Severe Headaches
Epilepsy of Fits
Dizziness or Fainting Spells
"Stingers" or "Burners"
Concussion or been "knocked out"
Loss of Memory
Any Mental Health Concerns
Motion Sickness
Frequent or Painful Urination
Sexually Transmitted Infections
Alcohol Use
Non-prescription/ street drug use
Tobacco Use
Tumor or Cancer
Kidney stones or blood in urine
Diabetes
Allergies
Skin Rashes
Arthritis
None
Other
Please check all that apply and provide details:
Have you ever been treated for an infectious disease in the last 12 months?
If YES what disease:
Have you ever had any surgery?
If YES, for what:
Have you ever had any broken bones
If YES, which one(s):
Do you wear contacts or glasses?
If YES, which do you wear to play sports with:
Do you have an eye condition which requires you to wear a tinted visor while playing football? Medical note required
Have you seen a physiotherapist or a chiropractor?
If YES, for what:
Do you have any pins, plates or screws in your body from and bone or joint surgery?
If YES, where:
Do you wear any dental appliances such as braces or a plate?
Family History: Please check any illnesses that have affected family members past or present:
Family Illnesses
Diabetes
Neurological Disorders
High Blood Pressure
Allergies
Mental Health Concerns
High Cholesterol
Arthritis
Sickle Cell Anemia
Bleeding Problems
Kidney Disease
Gout
Heart Disease
Has any one in your family died suddenly before the age or 40?
Please list any medications you are taking:
List any allergies (i.e. medications, bees):
When were your immunizations last updated (including tetanus)?
Provide details of any prior injuries (including location such as hand, elbow, neck, hip, ankle, shin/calf, wrist, knee, foot, arm, chest, thigh, shoulder, back):
Submit
Should be Empty: