Special Olympics Medical Form printable pdf download

Athlete Medical Form - MedFest

County

Fayette

New Athlete:

☐ No

☐Yes

To be completed by Special Olympics Kentucky:

MedFest®

☐ Healthy Young Athletes ☐ Individual Physical

ATHLETE INFORMATION

First

Middle

Last

Name:

Date Birth

(mm/dd//yyyy)

Female: ☐

Male: ☐ Insurance:

Address:

Athlete‘s Primary Care

Physician Name:

City

State

Zip

Athlete‘s Primary Care

(

)

Physician Phone:

Phone:

(

)

Cell:

(

)

Athlete’s Primary Care

Physician Address:

E-mail:

Eye

City/State/Zip:

color:

Does the athlete have (check any that apply):

List any sports the athlete wishes to play:

☐ Autism

☐ Down syndrome

☐ Fragile X Syndrome

☐ Cerebral Palsy

☐ Fetal Alcohol Syndrome

☐ Other syndrome, please specify:

Is the athlete allergic to any of the following (please list):

Does the athlete use (check any that apply):

☐ Dentures

☐ Communication Device

☐ Wheel Chair

☐ Food:

☐ Brace

☐ Removable Prosthetics

☐ Crutches or Walker

☐ Splint

☐ Glasses or Contacts

☐ Hearing Aid

☐ Medications:

☐ Pacemaker

☐ G-Tube or J-Tube

☐ Implanted Device

☐ Inhaler

☐ Colostomy

☐ C-PAP Machine

☐ Insect Bites or Stings:

☐ Latex

☐ No Known Allergies

List all past surgeries and dates:

List any special dietary needs:

List all ongoing or past medical conditions:

List all medical conditions that run in the athlete’s family:

Does the athlete have any religious objections to medical treatment? ☐ No

☐ Yes If yes, explain ________________________________________

Has any relative died of a heart problem before age 40?

☐ No

☐ Yes

Has any family member or relative died while exercising?

☐ No

☐ Yes

Has the athlete ever had an abnormal Electrocardiogram (EKG)?

or Echocardiogram (Echo)?

Does the athlete currently have any chronic or acute infection?

☐ No

☐ Yes

☐ No ☐ Yes

If yes, please circle EKG or Echocardiogram and describe below:

If yes, please describe below:

Has a doctor ever limited the athlete’s participation in sports? ☐ No ☐ Yes

If yes, please describe: ____________________________________________

__________________________________________________________________________________________________________________________________________

Has the athlete had a Tetanus vaccine within the past 7 years? ☐ No ☐ Yes

Is athlete his or her own guardian?

☐ No ☐ Yes

PARENT OR

GUARDIAN INFORMATION

First:

Middle:

Last:

Cell:

Phone:

(

)

(

)

E-mail:

Special Olympics Kentucky NEW Medical Form - Updated June 2015 | 1

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Special Olympics Medical Form

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