2024 World Transplant Winter Games - Donor Athlete Medical Form

Donor Family / Living Donor Athlete Medical Form

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

You MUST visit the Doctor-in-charge of your care in order to get your accurate medical data and ensure that your Doctor is happy for you to compete in your chosen sports. Completion of these forms confirms that you have indeed visited your doctor to obtain this information.

Medical Forms must be submitted by the close of Registrations (12th January 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 in the Games.

Before competing in the World Transplant Winter Games, it is expected that your general health and fitness are stable as judged by your 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. The 3 stress levels are shown below:

LOW STRESS:

* Curling

MEDIUM STRESS:

* Snowshoe Individual

HIGH STRESS:

* Ski Slalom / Ski Giant Slalom / Ski Super Giant Slalom / Ski Parallel Slalom

* Snowboard Giant Slalom / Snowboard Parallel Slalom

* Cross Country Ski 5km / Cross Country Ski 1 hour

* Biathlon

Team Country*

URN (Unique Reservations Number received by email when you registered for the Games eg: GMS2134)*

Name*

First NameLast Name

Date of Birth: *

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)*

Are you a Living Donor?*

YesNo

If YES, Organ or tissue donated?

KidneyLiverBone MarrowOther

Date of donation

Date

Are you a family member of a deceased donor?*

YesNo

Are you a family member of a living donor?*

YesNo

*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*

I intend to take part in the following sports in Bormio, Italy*

Baseline Blood Pressure *

Please answer Yes or No to the following questions:*

	YES	NO
History of High Blood Pressure
Are you pregnant
Are you on anticoagulants
Do you have diabetes mellitus
Do you have ischaemic heart disease
Do you have epilepsy
Do you have asthma
Have you had a heart or lung operation

If you have had a heart or lung operation - please provide details?

Do you have a respiratory disease?*

YesNo

If you said YES to a respiratory disease please provide more details

Please state any medication you are allergic to?

Please state anything else you are allergic to?

Do you have a history of COVID-19 Infection*

YesNo

If yes, provide date of last infection

Date

If applicable, please state the number of COVID 19 vaccinations doses you have had

Brand of last dose?

Date of last dose?

Date

A cardiac stress test is not essential in those with a history of coronary artery disease or over the age of 50 undertaking medium and high stress sports events.

However, 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

*Please complete the table below

	Condition	Required Medication	Dose / frequency
1.
2.
3.
4.
5.

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*

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

I agree that my data will be transferred to an online system for access and used by the World Transplant Winter Games 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 World Transplant Winter Games 2024?*

YesNo

I agree that after the Games 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

Electronic Signature*

Date*

Date

COMPETITOR DETAILS

DONOR DETAILS

FITNESS INFORMATION

MEDICAL INFORMATION

CARDIAC STRESS TEST

CURRENT MEDICATION

MEDICAL DOCTORS DETAILS

Data Storage and Participation in Clinical Research

DECLARATION