MEDICAL HISTORY

Please Print clearly

NAME OF PLAYER
(Surname) (First name)

/D
(Date of birth)

/M

/Y

AGE

RFID SPORT FAMILY PHYSICIAN

(Surname) (First name) (Phone #)

(City)

(Province)

EMERGENCY CONTACT
(Surname) (First name) (Phone #)

(City)

(Province)

PROVINCIAL HEALTH CARD*

(Number) (Version Code) (Province)
*Your physician medical care on site is covered by the provincial health plans and will require a valid health card. Please bring your health card to the medical room when you require service or provide us with the information on this registration form and we will ensure that the medical clinic has it.

HEALTH QUESTIONNAIRE 1. Have you ever been hospitalized? ..................................................................................................... 2. Are you presently taking any medication or pills? .. 3. Have you ever passed out during or after exercise? ......................................................................... 4. Have you ever been dizzy during or after exercise? ...................................................................... 5. Have you ever had chest pain during or after exercise? ................................................................... 6. Do you have trouble breathing or do you cough during or after activity? .......................................... 7. Do you use any special equipment (pads, scrum cap, brace, eye guard etc.)................................... 8. Have you had any problem with your eyes or vision? ....................................................................... 9. Do you wear glasses or contacts or protective eye wear? ................................................................ 10. Do you have problems hearing or use a hearing device? ............................................................... 11. Do you have asthma? ..................................................................................................................... 12. Do you have a heart condition? ...................................................................................................... 13. Do you have Diabetes? Type 1_
For what purpose?

YES

NO

Type 2_

14. Do you wear a medical information bracelet or necklace? ........... If YES to any of the above please provide further explanation

PAST MEDICAL SUMMARY

HISTORY

Please list any medical problems or injuries that you have had in the last two (2) years including tests, xrays, medications or treatment received. If you are still experiencing these problems please list the status as ongoing and if the problem has been resolved, please list the status as resolved. Date Problem or Injury Treatment Current Status

Have you had any surgery? Please describe: Do you have any upcoming medical test or doctors appointments? Please describe: If you are currently receiving any rehabilitation treatment please specify below: Are you currently wearing any type of adaptive equipment in partial treatment or protection for any existing injury or condition (eg orthotics, brace, helmet, etc.)? Please describe:

Type of treatment (physiotherapy, massage, Chiropractor, Athletic Therapy, etc.)

Name of provider

City and phone number of provider

ALLERGIES
Medication : Food : The environment :

Please list any allergies you may have to:

COMMENTS: Head Injuries/Concussions: 1. Have you ever had a head injury? . 2. Have you ever had a concussion or been knocked out, bell rung or been dinged? ....................... If yes please list: Number
Date(s) Activity at the time Length of unconsciousness Length of time before full return to activity

Yes

No

4. Have you ever had a stinger, burner or pinched nerve?....................................................................

3. Have you ever had a neck injury? (ie strain, sprain, fracture etc.)......