NAIT OOKS Male Medical Form
Preamble
An athlete will not be given the opportunity to participate further with NAIT Athletics until:
a) The NAIT Ooks Medical Form is completed;
b) The NAIT medical staff has reviewed the submitted medical form and have granted clearance for participation.
The Process:
a) ALL athletes that are returning and/or trying out for a NAIT team are required to complete the NAIT Ooks Medical Form.
- In the event that further evaluation by a NAIT medical staff is required, you will be contacted to make an appointment with our medical staff.
b) Athletes are required to submit the completed form to the Head Coach at a pre-determined date prior to the first team meeting or practice / tryout. If there are exceptional circumstances with respect to timelines, contact your Head Coach.
c) If this form is not submitted before the first day of tryouts, YOU WILL NOT PARTICIPATE until it has been received and reviewed by the medical staff.
Questions have been designed to help maintain the best possible health of our athletes.
All of your answers are confidential.
- If there is anything you wish to discuss, please contact our medical staff anytime.
NAIT Ooks Medical Form* 2012-2013 Season Sport ______
To Be Completed By The Athlete Year of eligibility:_____
Last Name: ______First Name: ______
Local Address: ______City______Prov.____ Postal Code ______
Local Phone ( ) ______E-Mail:______
Date of Birth ______Provincial Health Care #: ______Province: _____
(Month/Day/Year)
If Different from above:
Permanent Address ______City ______Prov.____ Postal Code ______
Home Phone ( ) ______
Do you have other Medical Insurance? NO / YES Plan Name ______Policy #:______
Emergency Contact: ______Relationship: ______
Address: ______Phone: ______
Section A - Please EXPLAIN “YES” answers below
With respect to your annual physical examination and ongoing medical care:
1. Do you have allergies to any medications ...... YES NO
2. Do you have other allergies (e.g. food, insects, etc.) ...... YES NO
3. Do you, or have you ever been told you have high or low blood pressure……………………………………...YES NO
4. Do you, or have you ever been told that you have an irregular heart beat, or heart murmur ………………….. YES NO
6. Do you have asthma…….. YES NO Do you have an inhaler………………………………………………….YES NO
7. Do you have epilepsy, or history of seizures...... YES NO
8. Do you have any ear or hearing trouble...... YES NO
9. Have you ever had blood clots…………………………………...... YES NO
10. Do you have any form of hepatitis……………………………………………………………………………....YES NO
11. Do you have HIV/AIDS………………………………………………………………………………………...YES NO
12. Do you have any other medical conditions……………………………………………………………………...YES NO
13. Do you have / have you had mononucleosis...... ………….. YES NO
14. Within the last year have you had any illness or medical condition lasting longer than one week ...... YES NO
15. Within the last year have you been admitted to hospital ...... YES NO
16. Are you now on, or have you been advised to be on, any medication on a regular basis ...... YES NO
17. Are you now on, or have you been advised to be on, any supplements on a regular basis ...... YES NO
18. Do you have abdominal pains (eg.hernias, ulcers etc) ...... YES NO
19. Do you have skin problems ...... YES NO
20. Do you have unexplained weight change ...... YES NO
21. Do you have any problems with your eyes or vision...... YES NO
22. Do you have bone or joint pains not related to injury...... YES NO
23. Have you ever had surgery ...... YES NO
24. When was your last tetanus shot...... ______
25. Have you had any other immunizations ie. Meningitis/Hepatitis B...... YES NO
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Family History Questions
Has anyone in your family had any of these illnesses? (if yes, please circle)
- Diabetes, allergies, arthritis, gout, neurological disorders, heart disease, high blood pressure, high cholesterol, bleeding problems, kidney disease, sickle cell anemia.
Section B - Please EXPLAIN “YES” answers below
As a result of your participation in sport: (explain “YES” answers below)
1. Have you ever passed out during exercise?
2. Have you ever experienced coughing or wheezing ...... YES NO
3. Have you ever experienced chest pain or severe shortness of breath ...... YES NO
4. Have you ever experienced fainting or dizzy spells ...... YES NO
5. Have you ever experienced heat exhaustion or heat stroke ...... YES NO
6. Have you ever experienced muscle cramps ...... YES NO
7. Within the last year have you had an injury requiring you to miss more than one practice or game ...... YES NO
8. Within the last year have you had an injury requiring therapy or other treatment ...... YES NO
9. Have you ever had surgery? If so, on what and when______YES NO
10. Do you have any pins, screws or plates in your body from any surgery?...... YES NO
11. Have you ever had concussions or head injury ...... YES NO
12. How many?______
13. When was the last one? ______
14. Have you ever been knocked unconscious or suffered loss of memory?...... YES NO
15. Have you ever had burner, stingers or neck injury ...... YES NO
16. Have you had frequent or severe headaches ...... YES NO
17. Do you currently have an incompletely healed injury ...... YES NO
18. Have you started using any special equipment (pads, braces, orthotics, etc) ...... YES NO
19. Do you wear glasses, contacts or protective eyewear (in practices or games)...... YES NO
20. Do you use any dental equipment...... YES NO
21. Do you have anything you wish to discuss with our medical staff...... YES NO
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Previous Injuries:
Check any areas that you have INJURED IN THE PAST and explain the injury below:
Hand Elbow Neck Hip Shin/Calf
Wrist Arm Chest Thigh Ankle
Forearm Shoulder Back Knee Foot
If you answered yes to any of the questions above please provide details and current status :
Date of Injury Type of Injury Is it still a problem? (Yes/No) Currently Receiving Care? (yes/no)
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I hereby certify the above information to be correct.
Athlete Signature: ______Date:______
If under 18 years of age,
Parent or Guardian signature: ______
Print Name: ______Date:______
* The information contained on this medical form may be used by the NAIT Therapy Staff in order to provide appropriate medical care. These records will be managed in accordance with the Health Information Act
2012-2013 Athletic Season