Medical Consent Form

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P3 – Medical Consent Form
Version 10 – 01/2014
Adventurous Journey Destination:
START DATE:
/
/
FINISH DATE:
/
/
Award Unit:
PARTICIPANT DETAILS
First Name
Surname
Home Phone
Other Phone
Address
Do you identify as an Aboriginal or Torres Strait Islander person?
Yes
No
EMERGENCY CONTACT DETAILS
Contact Person
Relationship
Phone (home)
Phone (other)
MEDICAL DETAILS
Date of Birth:
/
/
Weight:
kgs
Gender
Height:
cms
:
Do you have, or have ever had, any of the following?
Yes
No
Yes
No
Yes
No
Asthma
Heart Problems/
If yes, date of last episode & any medication you use
Diabetes
Disease
Drug Allergy
High Blood Pressure
Bleeding Condition
If yes, please circle
Penicillin
Morphia
Other:
Other Allergies
Recent Illness/ Injury
Mental Health Issue
If yes, please state
If yes, please state
Do you have any disability
Fears/ Phobias
Other Condition
If yes, please state
If yes, please state
Date of Last Tetanus Injection:
Within last 2 years
last 10 years
over 10 years ago
Never
If the need arises do you give permission for the young person to be administered paracetamol?
Yes
No
Current Medications:
list all medications you presently use -including prescription and over the counter medication
Medication __________________ Dosage __________
Frequency _________________ Treatment for ___________________
Medication __________________ Dosage __________
Frequency _________________ Treatment for ___________________
Medication __________________ Dosage __________
Frequency _________________ Treatment for ___________________
Parental Permission for DOE staff to administer medication
Yes
No
Swimming Ability
:
Excellent
Confident
Some Confidence
Not Confident
Do you have any special dietary requirements?
Yes
No
If yes, please state
Private Health Fund
If Yes, please state details
Medicare No: ____________________________
Place on card:
Expiry date:
/
/
The Duke of Edinburgh’s Award
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