Med Form 1
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MEDICAL INFORMATION SHEET
Date of birth: Day
Month
Year
Address: PostalCode:
Telephone: (_
)
Mother'sName:
Father'sName:
Business TelephoneNumbers: Mother
Father
Alternate emergenq/contact (if parentsare not available) Name:
Telephone:
Address: Doctor'sName:
Telephone: (_
)
Dentist'sName:
Telephone: (_
)
Date of lastcompletephysicalexamination: + Beforea playerparticipatesin a hockeyprogram,any medicalconditionor injury problemshouldbe checkedby that individuallfamilyphysician. Pleasecirclethe appropriateresponseand providedetailsbelow if you answer"Yes"to anyof the questions. Yes
No
Previoushistory of concussions
Yes
No
Faintingepisodesduringexercise
Yes
No
Epileptic
Yes
No
Wears glasses
Yes
No
Are lensesshatterproof
Yes
No
Wears contact lenses
Yes
No
Wears dentalappliance
Yes
No
Hearingproblem
Yes
No
Asthma
Yes
No
Troublebreathingduringexercise
Yes
No
Heart Condition
Yes
No
Diabetic-Type l_Type
Yes
No
Medication
Yes
No
Allergies
Yes
No
Wears a medicalinformationbraceletor necklace For what purpose?
2_
H ocK E Y
TR A IN E R S C E R TIFIcA TtoN
P R oGR A M
Date of birth: Day
Month
Year
Address: PostalCode:
Telephone: (_
)
Mother'sName:
Father'sName:
Business TelephoneNumbers: Mother
Father
Alternate emergenq/contact (if parentsare not available) Name:
Telephone:
Address: Doctor'sName:
Telephone: (_
)
Dentist'sName:
Telephone: (_
)
Date of lastcompletephysicalexamination: + Beforea playerparticipatesin a hockeyprogram,any medicalconditionor injury problemshouldbe checkedby that individuallfamilyphysician. Pleasecirclethe appropriateresponseand providedetailsbelow if you answer"Yes"to anyof the questions. Yes
No
Previoushistory of concussions
Yes
No
Faintingepisodesduringexercise
Yes
No
Epileptic
Yes
No
Wears glasses
Yes
No
Are lensesshatterproof
Yes
No
Wears contact lenses
Yes
No
Wears dentalappliance
Yes
No
Hearingproblem
Yes
No
Asthma
Yes
No
Troublebreathingduringexercise
Yes
No
Heart Condition
Yes
No
Diabetic-Type l_Type
Yes
No
Medication
Yes
No
Allergies
Yes
No
Wears a medicalinformationbraceletor necklace For what purpose?
2_
H ocK E Y
TR A IN E R S C E R TIFIcA TtoN
P R oGR A M
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