Medical Form Template For Mha'S - Ramp Interactive

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MEDICAL FORM TEMPLATE FOR MHA’S
To be completed by the athlete
Last Name ________________________________________________ First Name ________________________________________
Address ______________________________________________ City____________________________ Province _____________
Date of Birth _________________________ Home Phone # (
) __________________ Postal Code ___________________
Day
Month
Year
Health Care # __________________________________________________ Province ______________________________________
FOR EMERGENCY NOTIFY: Name _________________________________________
Relationship_________________________
Address _________________________________________________________ Phone_____________________________________
Family Doctor's Name _______________________________________ Date of Last Physical ________________________________
Month
Year
Sport:____________________________________________________
Year of Participation in Sport (circle):
1st
2nd
3rd
4th
5th
6th
th
Year of Participation in Hockey (circle):
1st
2nd
3rd
4th
5
6th
What position will you be playing this year?__________________________
Explain “Yes” answers below:
Yes
No
1.
Have you ever been hospitalized?............................................................................................................................ o
o
Have you ever had surgery?..................................................................................................................................... o
o
2.
Are you presently taking any medications or pills? ................................................................................................... o
o
Are you presently taking any vitamins or supplements? ........................................................................................... o
o
3.
Do you have any allergies (medicine, bees or other stinging insects)? .................................................................... o
o
4.
Have you ever passed out during or after exercise? ................................................................................................ o
o
Have you ever been dizzy during or after exercise? ................................................................................................. o
o
Have you ever had chest pain during or after exercise?........................................................................................... o
o
Do you tire more quickly than your friends during exercise? .................................................................................... o
o
Have you ever had high blood pressure? ................................................................................................................. o
o
Have you ever been told that you have a heart murmer? ......................................................................................... o
o
Have you ever had racing of your heart or skipped heartbeats? .............................................................................. o
o
Has anyone in your family died of heart problems or a sudden death before age 50? ............................................. o
o
5.
Do you have any skin problems (itching, rashes, acne)?.......................................................................................... o
o
6.
Have you ever had heat or muscle cramps? ............................................................................................................ o
o
Have you ever been dizzy or passed out in the heat? .............................................................................................. o
o
7.
Do you have trouble breathing or do you cough during or after activity? .................................................................. o
o
8.
Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guards, etc.)?............................... o
o
Do you use any dental appliances? .......................................................................................................................... o
o
9.
Have you had any problems with your eyes or vision? ............................................................................................. o
o
Do you wear glasses or contacts or protective eye wear? ........................................................................................ o
o
10. Have you had any other medical problems (infectious mononucleosis, diabetes, etc.)? .......................................... o
o
11. Have you had a medical problem or injury since your last evaluation?..................................................................... o
o
12. Have you had any unexplained weight change?....................................................................................................... o
o
13. When was your last tetanus shot? __________________________
When was your last measles immunization? ______________________
____________________________________________________________________________________________________________
14. Female Athletes: Over the past year, did your periods occur about once a month? .............................................. o
o
____________________________________________________________________________________________________________
Explain “Yes” answers
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
(Over ?)

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