Australian Kung Fu (Wu Shu) Federation
ACT/NSW Championships 2006 Medical Screen
Instructions to Participant
Dear Participant,
This evaluation is required to be completed for participants in the contact part of the ACT/NSW AKWF Championships. You do not need to have this completed if you are only competing in the forms or non-contact competiton.
The purpose of this form is to enable to medical staff to adequately treat you in the case of an injury or medical emergency during the competition. There are also certain medical conditions that are extremely risky in a contact situation and it is the AKWF medical staff’s right to preclude you from competing in the contact competiton if it is judged that the risk of competing is too great for either yourself or for other competitors. The information on this form will only be viewed by the medical staff and only used for the purposes of medical screening and treatment. If you are precluded from competing the organisers will be informed but are not privy to your medical details.
Steps:
- Fill out the participant details and questionnaire and release of information declaration.
- Attend your usual general practitioner to fill out the medical certificate. As part of this assessment you will probably have to have some blood tests performed. Your doctor will charge you appropriately for this certificate to be filled.
- Send in the completed forms to be received by 16th September 2006 to :
Dr Wilson Lo
AKWF Doctor
PO Box 413
Belconnen ACT 2616
- You may be required to have further history or examination after this and you will be contacted if this is the case or if it is felt that you are unfit to compete.
Yours sincerely
Dr Wilson Lo,
Tournament Doctor
Participant Questionnaire
PARTICIPANT DETAILS:
Name……………………………………………………..DOB………………………
Address……………………………………………………………………………………
……………………………………………………………………………………………
Phone (H)……………………..(W)……………………..(M)…………………..
Email address……………………………………………………………………….
MEDICAL HISTORY:
Have you ever had:
Diabetes Mellitus Y/N Seizures Y/N Asthma Y/N Heart Disease Y/N
Fainting episodes Y/N
Episodes of unexplained chest pain, shortness of breath or racing of the heart Y/N
Any surgical operations Y/N Hepatitis B or Hepatitis C or HIV/AIDS Y/N
If you have answered Y to any of the above please provide further details………………
……………………………………………………………………………………………….
……………………………………………………………………………………………….
Have you had any recent injuries or any medical conditions that may be a concern during a contact competition and if so, please provide details
…………………………………………………………………………………………..
Do you participate in regular sporting activities and if so what do you do?
……………………………………………………………………………………….
Have you any allergies and if so, what reaction occurs when you are exposed?
…………………………………………………………………………………
Signature of participant……………………………………..Date………………….
Release of Information Declaration
I, …….…………………………(Name of participant) declare that I give permission to
Dr …………………………………………………(Name of General Practitioner) to fill
in a medical certificate for the purposes of medical screening and treatment in the AKWF
ACT/NSW Championships in 2006. I also agree that any information on my health has
been supplied truthfully as far as I am aware and that any omissions by me may lead to
a medical emergency, in which case the medical staff of the tournament may not be able
to treat my condition adequately.
Signature of participant…………………………………………………
Date:………………………….
Signature of Witness………………………………………….
Name of Witness…………………………………………….
Date.,………………………………………………………..
Instructions to Medical Practitioner
Dear Doctor,
Thank you for completing this medical certificate for this participant. He/She is applying to compete in a contact martial arts tournament in September 2006. Although there will be some protective equipment there is always a risk of physical injury and the participant is aware of this. This certificate is part of a screening process that makes the medical staff aware of any existing medical conditions that may lead to sudden death or a medical emergency. The AKWF medical staff will contact the participant after receiving this certificate if furtherhistory or examination is required. The AKWF medical staff may preclude the participant from contact competition if it is thought that the risk to the participant or to others is significant based upon pre-existing conditions.
Yours sincerely
Dr Wilson Lo
Tournament Doctor
Phone 02 6251 1711
AWKF ACT/NSW Championships September 2006
Certificate by Medical Practitioner
Name of Participant………………………………………………
DOB of Participant……………
1. Are you the usual medical practitioner of this participant? Y/N
How long have you known the participant?......
2. Based upon your history has the participant had any of the following conditions currently or in the past? If Yes, please comment on stability of condition and current treatment.
Epilepsy Y/N Diabetes Mellitus Y/N Asthma Y/N Concussion Y/N
Carrier of HIV/Hepatitis B/Hepatitis C Y/N Ischaemic Heart Disease Y/N
Congenital Heart Disease Y/N
Comments on the above conditions…………………………………………………….
…………………………………………………………………………………………
3. Does the participant have any allergies and if so, what reaction occurs with exposure?......
4. As far as you are aware does the participant have any injuries or medical conditions that preclude him/her from participating in a contact martial arts competition? If so, please comment.
…………………………………………………………………………………………………………………………………………….
5. As fare as you are aware does the participant engage in any risky behaviour that may lead to the contraction of Hepatitis B, Hepatitis C or HIV?......
……………………………………………………………………………………………
6. Regular medication of the participant……………………………………………..
7. PHYSICAL EXAMINATION:
Pulse Rate:………. regular? Y/N Blood Pressure…………Heart sounds/murmurs……
8. INVESTIGATIONS:
Please give the results (or attach) of the following tests – these need to taken in the last twelve months before competition:
Hepatitis C antibody…………………………date……………
HIV antibody………………………date…………………
Hepatitis B surface antigen (or alternately evidence that the participant has had a full course of Hepatitis B vaccinations at any time in their lives)……………………..date…………………..
ECG only if over 40 y.o. at time of competition…………………
Thank you very much for your time and expertise with this certificate.
Medical Practitioners Details:
Signature………………………………………….Date……………
Name, Address, Phone Number and Provider Number (or stamp)
………………………………………………………………………………………………
………………………………………………………………………………………………
……………………………………………………………………………………………..