Boxing Ontario Medical Form
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1Boxing Ontario Medical Form
(To be filled out by a Licensed Medical Physician Only (MD). Please print clearly)
Athletes Information
Name___________________________________________________________________Date of Birth______________________________
Address_____________________________________________ City____________________ Province ON Postal Code________________
Telephone Number_____________________ Email Address_____________________________ Club_______________________________
Please note that medical forms submitted to Boxing Ontario that are dated 6 months or over will not be accepted!
Please note that the following may prelude 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, Organomegaly or Undescended Testis (8) Heart Lesions.
Weight____________________ Height _____________ Expiration__________________________ Inspiration________________
Vision: Right Eye__________/______________ Left Eye ________/_____ Colour Vision_____________ Field of Vision_______
Urinalysis (Labetix): Sugar____________________ Protein__________________ Blood____________________________________
Concerns Past or Present
Yes
No
Comment
Eye or ear impairment, infections or injuries
Rheumatic fever, TB, pleurisy or asthma.
(a chest X-ray is required only if there is a family
history of TB).
Kidney or urine disorder, one kidney
Diabetes mellitus
Indigestion, vomiting, abdominal cramps
Nervous breakdown, head injury, fits
Acute Infections
Fractures, dislocations, severe sprains
Epilepsy, of application or in family
Ears(state of T.M.S. and degree of deafness)
Teeth – any braces
Is there any abnormality in chest, heart , BP or C.N.S.
Is there a hernia, undescended testis, organomegaly,
cryptorchidism
Have there been any medical suspensions from Boxing
Female Specific (Please note that confirmed pregnancy disqualifies from Boxing)
Concerns Past or Present
Yes
No
Comment
Are there breast lesions, bleeding, masses, other
dysfunction, pain
Is there any abnormality in menstrual pattern?
amenorrhea??
Lower pelvic pains
I _______________________________________ certify that ______________________________________
(Licensed Medical Physician (MD) Name)
(Athletes Name)
IS FIT
/ IS NOT FIT
to engage in Boxing.
(please check one)
Physicians Signature______________________ CPSO License #___________________Date Medical Conducted_____/______/______
Day
Month
Year
Address: ___________________________________________ Telephone Number_______________ Fax Number___________________
Boxing Ontario Applicant Signature_______________________________________________ Date _____________________________
(Parental/Guardian signature if applicant is age 17 and under)
DK 9/12
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