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MEDICAL INFORMATION SHEET Name: _________________________________________ M______ F_________ Date of Birth: Day ____. Month___________________ Year ___ Address: ____________________________________________________________ Postal Code: _________________ Telephone: ____________________________ Provincial Health Number: ______________________________________________ Mother's Name: ____.________________ Father's Name: ______________ Business Telephone Numbers: Mother: _.____________ Father: _______ Person to contact in case of accident or emergency, if parents are not available Name: __________________________ Telephone: __________________ Address: ____________________________________________________ Doctor's Name: _______________________ Telephone: ______________ Dentist's Name: _______________________ Telephone: ______________ Please circle the appropriate response below pertaining to your child: *Previous history of concussions ________________ YES NO *Fainting episodes during exercise _______________ YES NO *Epileptic ________________ ____________________ YES NO *Wears glasses ________________ ________________YES NO *Are lenses shatterproof _________________________YES NO *Wears contact lenses __________ ________________YES NO *Wears dental appliance _________ ________________ YES NO *Hearing problem _______________ ________________YES NO *Asthma ____________________ _________________YES NO *Trouble breathing during exercise ______ ___________YES NO *Heart condition____________ ____________________YES NO *Diabetic _____________________________________ YES NO *Medication __________ _________________________YES NO *Allergies ____________ _________________________YES NO--please list____________________________ *Has had an illness lasting more than a week ___________YES NO in the past year Strathroy Skating Club page 1 of 2 |
| *Wears a medic alert bracelet or necklace ________ ___________YES NO *Does your child have any health problems that would ________ YES NO interfere with participation in a skating program *Surgery in the last year _____________ ____________________YES NO *Has been in hospital in the last year _______________________ YES NO *Has had injuries requiring medical attention in the _____________YES NO past year *Presently injured ____________ _________________________YES NO Please give details below if you answered "yes" to any of the above items: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ (use separate sheet if necessary) Medications:___________________________________________________________________________ Allergies: ____________________________________________________________________ Medical Conditions ____________________________________________________________ Recent Injuries: ________________________________________________________________ Last Tetanus Shot: _____________________________________________________________ Any information not covered above:_________________________________________________ ____________________________________________________________________________ Date of last comptete physical examination:__________________________________________________ *Any medical condition or injury problem should be checked by your physician before participating in a skating program. *I understand that it is my responsibility to keep the Strathroy Skating Club advised of any change in the above information as soon as possible and that in the event no one can be contacted, management will take my child to hospital/M.D. if deemed necessary. *I hereby authorize the physician and nursing staff to undertake examination, investi- gation and necessary treatment of my child. *I also authorize release of information to appropriate people (coach, physician) as deemed necessary. Date:________________ Signature of Parent or Guardian: _______________________________ "SAFETY REQUIRES TEAMWORK" Strathroy Skating Club Paae 2 of 2 |