Medical questionnaire asia oceania 2012.doc

ITF International Junior Tennis Camp
Camper / Staff Information and Medical Form
Athlete Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DOB: . . . . . . . . . . . . . . . . . . . . . . . Male / Female: . . . . . . Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City: . . . . . . . . . . . . . . . . State: . . . . . . . . . . Postcode: . . . . Country: . . . . . . . . . . . . . Email: . . . . . . . . . . . . . . . . . Phone Numbers (H): . . . . . . . . . (W): . . . . . . . . . . Mobile: . . . . . Does athlete use a wheelchair everyday? . . . . . . . . . . . . . . . . . . . . . Does athlete have a sports wheelchair? . . . . . . . . . . . . . . . . . . . . . . . How many years has athlete been playing Wheelchair Tennis? . . . . . . . . . . . . . Please list athlete’s most recent competitions, results and division: Tournament
Division
MEDICAL INFORMATION
Height: . . . . . . . . . . . . . . . . . . . Weight: . . . . . . . . . . . . . . Disability and/or level of injury: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of onset: . . . . . . . . . . . Doctor’s Name: . . . . . . . . . . . . . . Doctors Contact Information: . . . . . . . . . . . . . . . . . . . . . . . . . . Insurance provider and ID Number: . . . . . . . . . . . . . . . . . . . . . . . Name of Emergency contact person: . . . . . . . . . . . . . . . . . . . . . . . Relationship (eg Mother/Father/Guardian etc): . . . . . . . . . . . . . . . . . . . . Phone Numbers (H): . . . . . . . . . . (W): . . . . . . . . . . . Mobile: . . . . . Current Medications (include name of drug, dosage, and times a day when taken, if any): (Attach page if you require more space) Name of Medication
Time of Day Taken
Comments
(amount)
Drug allergies and/or other allergies? (Please describe): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
*** Please Note this will only be administered by a Doctor in an emergency ***
Which of the following over the counter medications does your child have permission to be
History of seizures (Yes / No)? . . . . . . . . Last one (date)? . . . . . . . . . . . . Medication Controlled (Yes / No)? . . . . . . . . . . . . . . . . . . . . . . . . . Has athlete been sick/ill in the last six weeks? . . . . . . . . . . . . . . . . . . . . If yes, state specific problems: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Has the athlete ever had any heart related problems (Yes / No)? . . . . . . . . . . . . . If yes, when and what happened: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Is athlete on a special diet (Yes / No): . . . . . . . . . . . . . . . . . . . . . . . Please Explain: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Does athlete have a shunt (Yes / No)? . . . . . . . . . . . . . . . . . . . . . . . If yes, state specific problems experienced: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Does athlete have any skin problems (Yes / No)? . . . . . . . . . . . . . . . . . . . If yes, state what and where: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Is athlete independent in all Activities of daily Living skills (Yes / No)? . . . . . . . . . . . Bladder (Yes / No): . . . . . . . . . . Bowel (Yes / No): . . . . . . . . . . . . .
NOTE: All campers are required to be independent with all activities of daily living to
attend this camp. The staff are not trained to provide attendant care, they are
coaches.
Please list any additional information we should know about the athlete attending camp: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I, . . . . . . . . . . . . . . . . state that the above information is correct. I also give permission to the Camp Director to forward this information to a medical practitioner (eg Doctor) to administer any medical treatment as needed for my child if . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . by Friday 21st September 2012
Anne-Marie Handke (Senior Community Tennis Officer – Northern Region)
Tennis SA
PO Box 43 North Adelaide SA 5006
Fax: +618 8212 6518 or Phone: + 618 7224 8104

Source: http://www.tennis.com.au/qld/files/2010/10/Medical-Questionnaire-Asia-Oceania-2012.pdf