Medical Declaration For Ifma Athletes
ADVERTISEMENT
1
2
3MEDICAL DECLARATION FOR IFMA ATHLETES
The information contained in this medical history form will only be used by the International Federation of Muaythai Amateur for purposes of
determining if you pose a health threat/risk to yourself in the ring and to review your past medical history in the event of a new emergency or re-
occurrence. This information will remain confidential at all times. Please complete this questionnaire with your physician. Print clearly in BLUE or
BLACK ink only.
PERSONAL INFORMATION
LAST NAME:
FIRST NAME:
M.I.
D.O.B.
AGE:
SEX:
NATIONALITY:
DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONDITIONS?
CONDITION:
YES
NO
CONDITION:
YES
NO
CONDITION:
YES
NO
BLEEDING OR OTHER BLOOD DISORDER
EPILEPSY/SEIZURE
CATARACTS
OPEN WOUND/SUTURED CUT
BLURRED VISION
DIABETES
HIGH TEMPERATURE/PYREXIA
HEARING LOSS
FAINTING
HEADACHES/MIGRAINES
BALANCE PROBLEMS
DIZZINESS
HIGH BLOOD PRESSURE
ASTHMA/BRONCHITIS
HERNIA
ANY HEART CONDITION
RECURRENT NECK PAIN
HIV
CHEST TRAUMA/RIB FRACTURE
RECURRENT BACK PAIN
HEPATITIS
CHRONIC OR ACUTE INFECTIOUS DISEASE
MENTAL ILLNESS
PREGNANCY
1)
ARE YOU OVER THE AGE OF 40? YES:
NO:
2)
HAVE YOU HAD A FIGHT THAT ENDED IN KO OR RSC-H IN THE PAST 6 MONTHS? YES:
NO:
3)
HAVE YOU EVER TESTED POSITIVE WITH WADA (WORLD ANTI-DOPING AGENCY)? YES:
NO:
4)
ARE YOU CURRENTLY TAKING ANY MEDICATION? YES:
NO:
*IF YES, PLEASE LIST ENSURE THAT YOU HAVE SUBMITTED A TUE FORM
5)
HAVE YOU HAD ANY TYPE OF SURGERY IN THE PAST 6 MONTHS? YES:
NO:
6)
HAVE YOU NEEDED IN-PATIENT TREATMENT IN A HOSPITAL IN THE LAST 6 MONTHS? YES:
NO:
7)
HAVE YOU RECEIVED TREATMENT FOR A BONE FRACTURE, FISSURE OR DISLOCATION IN THE LAST 6 MONTHS? YES:
NO:
8)
DO YOU NORMALLY WEAR EYE GLASSES OR CONTACT LENSES? YES:
NO:
9)
HAVE YOU EVER HAD BACK OR SPINAL SURGERY? YES:
NO:
PLEASE BE AWARE IF YOU ARE OVER 16 LABORATORY BLOOD TESTS RESULTS for HIV antibody & HBV (Hepatitis B Surface
Antigen) & HCV (Hepatitis C Antibody) must be submitted with this form on the letterhead of the laboratory that administered
the tests. The blood tests must be taken within 6 months prior to the date of competition.
Page 1 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Medication Authorization For Cms Students Form/authorization For Self-medication By Cms Students Form - 2006
Medical
Medical Documentation For Wic Formula And Approved Wic Foods For Infants, Children And Women
Medical
Related Categories
Parent category: Medical