U15 Major Bedford Bandits Health Form

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 Bandits 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.

U15 Major Bedford Bandits Health Form

U15 Major Bandits Health Form

Personal Information

Health History