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West Bedford Wolves Football Health Form
West Bedford Wolves Football Health Form
"
*
" indicates required fields
Personal Information
Name
*
First
Middle
Last
Birthdate
*
DD slash MM slash YYYY
Gender
Health Card #
*
Phone – Cell
*
Mailing Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Emergency Contact
*
Phone
*
Email
*
Relationship
*
Family Physician
Family Physician
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, Chiropractic or massage in the past?
No
Yes
Please check any that apply, past or present:
High or Low Blood Pressure
Heart Condition
Stroke/CVA
Pacemaker
Swelling/Edema
Phlebitis/Varicose Veins/Blood Clot
Cancer
Diabetes
Osteoporosis
Fibromyalgia
Hepatitis
Epilepsy
HIV/AIDS
Skin Condition
Bowel/Bladder/GI Issues
Numbness/Tingling/Paralysis
Respiratory Issues
Headaches/Migraines
Allergies
Presence of internal pins, plates, screws or artificial joints
Heart Condition, please list
*
Stroke/CVA date
*
MM slash DD slash YYYY
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
*
MM slash DD slash YYYY
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 West Bedford Wolves Football 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.
