Medical Information Sheet Template
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1
2MEDICAL INFORMATION SHEET
Name: _____________________________________________________________________________
Date of birth:
Day ___________ Month ___________ Year ___________
Address: ______________________________________________________________________________
Postal Code: _______________ Telephone: ( ____ ) _______________________ Cell: (___) ____________
Mother’s Name: ______________________________ Father’s Name: _______________________________
Business Telephone Numbers: Mother _________________________ Father _________________________
Alternate emergency contact (if parents are not available)
Name: _________________________________________________ Telephone: _____________________
Relationship to player: ____________________________________
Address: ______________________________________________________________________________
Doctor’s Name: ______________________________________ Telephone: ( ____ ) ___________________
Dentist’s Name: ______________________________________ Telephone: ( ____ ) ___________________
Date of last complete physical examination: ___________________________
* Before a player participates in a hockey program, any medical condition or injury problem should be checked by
that individual’s family physician.
Please circle the appropriate response and provide details below if you answer “Yes” to any of the questions.
Yes
No
Medication
Yes
No
Allergies
Yes
No
Previous history of concussions
Yes
No
Fainting episodes during exercise
Yes
No
Seizures and/or Epilepsy
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
Family History of Heart Disease
Yes
No
Diabetes
Type 1 ______
Type 2 _______
Yes
No
Wears a medical information bracelet or necklace
For what purpose? __________________
Hockey Trainers Certification Program
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Parent category: Medical