Athlete Medical Form - Special Olympics Connecticut

ATHLETE MEDICAL FORM

SPECIAL OLYMPICS CONNECTICUT

LOCAL PROGRAM:

PLEASE CHECK

______NEW

_____RENEWAL

Name (First – Last):

Date of birth: _________/_________/_________

Gender

____Male

____Female

Phone Home:

Street:

City:

State:

ZIP Code:

PLEASE LIST PARENT OR GUARDIAN INFORMATION BELOW

Name

Address (if different than athlete’s)

City

State:

ZIP Code:

Phone Home:

Work:

Mobile:

E-Mail

EMERGENCY CONTACT IF DIFFERENT THAN PARENT OR GUARDIAN

Name:

Relationship:

Phone:

Type:

HEALTH HISTORY TO BE COMPLETED BY PARENT/CAREGIVER

AN UP TO DATE HEALTH HISTORY AND A PHYSICAL EXAMINATION PERFORMED BY A LICENSED EXAMINER IS REQUIRED UPON ENTRY

INTO THE PROGRAM. A PHYSICAL EXAMINATION IS REQUIRED EVERY 3 YEARS FOR ATHLETES WITH “YES” RESPONSES TO ITEMS 1 -5.

A PHYSICAL EXAMINATION IS REQUIRED FOR ALL ATHLETES WITH A “NEW” RESPONSE TO ITEMS 7-11. ATHLETES MUST SUBMIT THIS

FORM EVERY 3 YEARS WHETHER OR NOT AN EXAMINATION IS NECESSARY.

1. HEART PROBLEMS

___YES ___NO

9. SURGERY OR ILLNESS

___YES ___NO ___NEW

17. EMOTIONAL/BEHAVIOR PROBLEMS

___YES ___NO

2. CHEST PAINS

___YES ___NO

10.HEAT STROKE/COLD ILLNESS

___YES ___NO ___NEW

18. BONE OR JOINT DISORDER

___YES ___NO

3. SEIZURES/EPILEPSY

___YES ___NO

11. OTHER PROBLEM (S) THAT WOULD INTERFERE

19. SICKLE CELL/TRAIT DISEASE

___YES ___NO

4. DIABETES

___YES ___NO

WITH SPORTS PARTICIPATION ___YES ___NO ___NEW

20. HEARING AID

___YES ___NO

5. DOWN SYNDROME

___YES ___NO

LIST: __________________________________________

21. CONTACTS/EYEGLASSES

___YES

___NO

5a. Atlanto-Axial Instability present

___YES ___NO

12. IMPAIRED MOBILITY

___YES ___NO

22. DENTURES/FALSE TEETH

___YES ___NO

5b. If yes, X-ray date

_________________________

13 DEAF

___YES ___NO

23. DATE OF LAST TETANUS SHOT

______/______/____

6. BLIND

___YES ___NO ___NEW

14. SPECIAL DIET

___YES ___NO

24. INSECT STING ALLERGY

___YES ___NO

7.ABSENCE OF KIDNEY/TESTICLE

___YES ___NO ___NEW

15. ASTHMA

___YES ___NO

25. MEDICINE ALLERGY (LIST BELOW)

___YES ___NO

8. HEAD INJURY/CONCUSSION

___YES ___NO ___NEW

16. BLEEDING PROBLEMS

___YES ___NO

26.FOOD ALLERGY (LIST BELOW)

___YES ___NO

Check all that apply

____Non Verbal

____Walker

____Crutches ____Wheelchair ____Hepatitis

LIST MEDICINE ALLERGIES:

LIST FOOD ALLERGIES:

MEDICATIONS: PLEASE PRINT MEDICATION NAME, AMOUNT AND NUMBER OF TIMES PER DAY MEDICATION NEEDS TO BE TAKEN BELOW:

(USE ADDITIONAL PAPER IF NEEDED)

HEIGHT:_________________

WEIGHT:_________________

LICENSED EXAMINER AND PARENT/CAREGIVER SIGN AND DATE BELOW

EXAMINERS NOTE: If an athlete has Down Syndrome, Special Olympics requires a full radiological examination establishing the absence of Atlanto-axial Instability before

he/she may participate in sports or events which, by their nature may result in hyperextension, radical flexion or direct pressure on the neck or upper spine. The sports and

events for which such a radiological examination is required are equestrian sports, gymnastics, diving, pentathlon, butterfly stroke, diving starts in swimming, high jump, alpine

skiing, squat lift and football team competition (soccer).

RESTRICTIONS:

DATE: ___________/__________/__________

EXAMINERS SIGNATURE:

DATE: ___________/_________/___________

EXAMINERS NAME:

PHONE: (

)

APPLICANT OR PARENT/GUARDIAN SIGNATURE:

DATE: __________/_________/___________

THIS FORM MUST BE COMPLETED LEGIBLY, SIGNED AND DATED TO BE CONSIDERED VALID.

Revised 2013