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Medical Form Junior Ice Wolves

Please fill out the following form for your player

Please note that any information given will remain confidential unless deemed appropriate / relevant to divulge to appropriate personnel.
(I.e. in case of emergency / serious injury/illness where participation is halted). (*required)
Emergency Contact Details
Please answer all questions
Do you have any allergies?
Do you have asthma?
Are you diabetic?
Do you have epilepsy?
Do you have any other medical conditions?
Have you experienced any mental health conditions?
Do you take any prescription medications or supplement?
Do you wear glasses or contact lenses?
Do you have any current injuries?
Have you seen a physiotherapist or sports medicine doctor for the injury/injuries?
Do you wear a mouth guard at training/competition?
Medical History. Please answer all questions
Have you ever had a heart problems?
Have you ever experienced irregular heart beat, heart palpitations or heart murmurs ?
Do you have high blood pressure or high cholesterol ?
Have you ever had a concussion?
Have you ever been treated for a head, neck or spinal injury ?
Have you had surgery within the past 3 years?
Have you spent time in hospital for any medical condition/ illness / injury during the past 12 months?
Have you ever had a hernia ?
Have you sustained a fracture or dislocation in the past 3 years ?
Do you experience any reoccurring pain in any muscle or joint during physical activity?
Do you ever experience pains in your chest during physical activity or at rest?
Do you ever experience dizziness or feel faint during physical activity ?
Have you ever fainted during physical activity ?
Do you have reoccurring migraines/headaches?
Have you ever experience exercise - induced migraines ?
Do you have chronic muscle tightness or cramping?

Player Declaration

I acknowledge that the information I have provided is to be used as a screening tool for the purpose of coaching and playing.

I hereby certify I believe that to the best of my knowledge, all of the information I have given is correct and true; I have read and understand the above information; I have answered all the questions to the best of my ability; I consider myself to be capable and in good health to participate in this sport and physical activity.
All information provided on this sheet is confidential. Access to this sheet is limited to Melbourne Junior Ice Wolves coaches, team manager, administration and medical team. Your personal details and medical information will not be made available to third parties unless permission to do so is granted by you.

Thanks for submitting!

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