Annual Boxers Medical Form
ADVERTISEMENT
1CANADIAN AMATEUR BOXING ASSOCIATION
Annual Medical Form
(please print clearly)
Part 1 – To be completed by athlete (male or female) or parent / guardian if under legal age
Name
______________________________________________ Date of Birth
______________________________
Address _________________________________________________________________________________________
______________________________________________________ Tel.
_____________________________________
BC Carecard # _________________________________________ Other
___________________________________
Weight
____________
Height
____________
Boxing Club
__________________________________________
If the applicant has or had any of the following illnesses, please give particulars in this space:
YES
NO
1. Eye or ear impairment, infections or injuries:
____
____
____________________________
2. Rheumatic fever, T.B., pleurisy or asthma:
____
____
____________________________
3. Kidney or urine disorder, one kidney:
____
____
____________________________
4. Diabetes millitus:
____
____
____________________________
5. Indigestion, vomiting, abdominal cramps:
____
____
____________________________
6. Nervous breakdown, head injury, fits:
____
____
____________________________
7. Acute infections:
____
____
____________________________
8. Fractures, dislocations, severe sprains:
____
____
____________________________
9. Epilepsy of applicant or in family:
____
____
____________________________
10. Any suspensions from boxing?
____
____
____________________________
____________________
_____________________________________
________________________________
Date
Signature of Athlete
Signature of Parent / Guardian
Part II – To be completed by the Physician
Note:
the following may preclude from boxing: (1) impaired vision – worse eye less than 20/120 and better eye less
than 20/60; (2) squint; (3) recurrent chronic suppurative otitis media; (4) chest expansion less than 2”; (5) total
deafness; (6) albuminuria; (7) hernia, organoommeegaly or undescended testis; (8) heart lesions.
WEIGHT __________
HEIGHT __________ EXPIRATION _________
INSPIRATION __________
VISION
Right eye 20/____________
Left eye
20/_____________
COLOUR VISION _____________________
FIELD OF VISION
__________________
EARS (state of T.M.S. and degree of deafness) ______________________________________________
TEETH (any braces)
__________________________________________________________________
Is there any abnormality in chest, heart, B.P. or C.N.S.? ________________________________________
Is there a hernia, undescended testis, organomegaly, cryptorchidism? _____________________________
Urinalysis (Labetix)
Sugar __________
Protein
___________
Blood
___________
Chest X-ray required only if there is a family history of T.B.
___________________________________
Additional for the female boxer: Note: confirmed pregnancy disqualifies from boxing.
Are there breast lesions, bleeding, masses, other dysfunction, pain? _______________________________
Abnormality in menstrual pattern? Amenorrhea?
_____________________________________________
Lower pelvic pain?
_____________________________________________________________________
I certify that the applicant is / is not fit to engage in boxing.
Physician’s name and Licence number ________________________________________________________________
Address
________________________________________________________________________________________
______________________________________________Telephone no.
_____________________________________
Signature
________________________________________________
Date
_______________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical