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