Player Medical Information Sheet
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1
2HOCKEY CANADA
PLAYER MEDICAL INFORMATION SHEET
Name:
____________________________________________________________________________________
Date of birth:
Day
Month
Year
__________
__________
__________
Address:
__________________________________________________________________________________
Postal Code:
Telephone:
_________________________________
_________________________________
Provincial Health Number:
__________________________________________________________________
Mother’s Name:
Father’s Name:
____________________________
______________________________
Business Telephone Numbers: Mother
Father
_____________________
________________________
Person to contact in case of accident or emergency, if parents are not available.
Name:
Telephone:
_________________________________________
_________________________________
Address:
____________________________________________________________________________________
Doctor’s Name:
Telephone:
_________________________________
_____________________________
Dentist’s Name:
Telephone:
________________________________
_____________________________
Please circle the appropriate response below pertaining to you child
Yes
No
Previous history of concussions
Yes
No
Fainting episodes during exercise
Yes
No
Epileptic
Yes
No
Wears glasses
Yes
No
Are lenses shatterproof?
Yes
No
Wears contact lenses
Yes
No
Wears dental appliance
Yes
No
Hearing problem
Yes
No
Asthma
Yes
No
Trouble breathing during exercise
Yes
No
Heart Condition
Yes
No
Diabetic
Yes
No
Has had an illness lasting more than a week in the past year
Yes
No
Medication
Yes
No
Allergies
HOCKEY CANADA SAFETY PROGRAM
19
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Parent category: Legal