Sample medical advice form – seniors (Confidential)


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NameSample medical advice form – seniors (Confidential)
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SAMPLE MEDICAL ADVICE FORM – SENIORS (Confidential)
To the Player,
The introduction of a standard Medical Advice Form is to assist those who care for you during the season to provide, as far as is humanly possible, a safe training and playing environment for you….personally. It is also meant to be used as a means of providing advice for you about an injury or condition you may have so that you can participate safely and gain full enjoyment out of playing the game of Rugby League.
It is not meant, in any way to be an invasion of your privacy, nor will it be used or given to any other person without your permission. The only people who will have access to this form will be the appointed Rugby League Sports Trainer for your club, club doctor, your private doctor or the honorary league doctor.
The effectiveness of this form in providing the above will only work if you complete this form honestly and view such a form in a positive manner.
You may be asked to have a medical evaluation before you play, this will be rare. If you are asked to have a medical evaluation, please view this as caring for you as a person. The basic aim then of this form is to provide the best possible care for these who matter most in the game of Rugby League, you the player.
I hope you have a successful and enjoyable season
Yours in Rugby League

…………………………………………………… ………………………………………………….

Club Sports Trainer Club President


Name




Club




Address










Telephone




D.O.B.




Family Doctor




Telephone




Medical Cover

Private

Medicare No.




I give permission to call an ambulance in an emergency

YES / NO

Name of person to contact in an emergency

Telephone




Relationship







Do you suffer from

Yes / No

Management

Diabetes







Asthma







Epilepsy







Do you experience any of the following signs and symptoms during training/playing?

Undue shortness of breath







Chest pain







Light headedness, dizziness or episodes of fainting







Become tired/fatigued easily








Continued


Allergies (please list)


Do you take any regular medications/s?

YES / NO

Type

Reason

Previous Injuries

When

Treatment

Fracture







Dislocation







Neck Injury







Back Injury







Ankle Sprain







Knee Problems







Do you require taping every game YES / NO Where?

Have you suffered concussion in the last 3 years? YES / NO

How many times? Treatment?

When did you have your last full medical checkup?

Have you had your full course of Hepatitis “B” injections? YES / NO

How long have you been playing Rugby League?

What position do you usually play?

Other information relevant to managing an injury you may sustain


Are you aware of the inherent risks of participating in physical activity such as Rugby

League? YES / NO

I declare this to be a true statement of my health status as at the date below

I will notify the Club Sports Trainer of any problem that may occur during the season that is relevant to my health status and playing Rugby League.

Signed: Date:

Checked By: Position in Club:

Checked By: Medical Practitioner:



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