U15 Major Gulls Health Form - MOVE Physiotherapy

Personal Information

Name*

First Middle Last

Birthdate*

Gender

Health Card #*

CCMI – Baseline Registration Number

Phone – Cell*

Email*

Mailing Address*

Street Address Address Line 2 City Province Postal Code

Emergency Contact*

Phone*

Relationship*

Family Physician

Family Physician

Physician Name*

Health History

Are you presently being treated for any health conditions?

No
Yes

Please list health conditions*

Are you presently taking any medications/vitamins/supplements?

No
Yes

Please list medications/vitamins/supplements*

Please list previous injuries and/or surgeries

Have you been to physiotherapy in the past?

No
Yes

Please check any that apply, past or present:

Heart Condition, please list*

Stroke/CVA date*

Pacemaker year of insertion*

Swelling/Edema cause if known*

Cancer, please list type and dates*

Diabetes, please list type*

Hepatitis, list type*

Epilepsy, is it controlled*

No
Yes

Date of last seizure*

Skin condition, please list*

Bowel/Bladder/GI Issues, please specify*

Respiratory Issues, please specify*

Allergies, please list*

Presence of internal pins, plates, screws or artificial joints, please list*

Are you currently immunocompromised?*

No
Yes

Please list anything else that your therapist should be aware of

Consent*

I accept

By submitting this form you are authorizing the U15 Major Gulls Team Therapists to:

*Undertake any examination, investigation and necessary treatment of my child. This includes removing my child from play when the team therapy staff deems it necessary for their health.

*Release any medical information to appropriate people (coach, physician) as deemed necessary by team medical staff.