Medical Disclosure Form

MEDICAL DISCLOSURE FORM

 

YOUR NAME …………………………………………………………………………………………

Personal medical information may help you in the unlikely event of an accident or in case of illness. Please complete the form as accurately and truthfully as possible. Please read through it carefully, before filling it out. The facts that you disclose will be held in confidence and will only be used to help staff, rescue workers, ambulance officers and doctors respond to an injury, accident or medical emergency. The form is held by the trip leader and will be returned to you after the activity or destroyed.

While the questions below seem very intrusive, we only want the information to supply to health or rescue professionals in an emergency. It is not our intention to exclude you from any activity because of your answers; in some cases we may counsel you as to the risks for both you and others in the group.

 

GENDER   male/female   AGE ……..(years)    Date of birth      .……/……./………

 

BLOOD TYPE ………..  Height ……….cms  Weight …………kg   BMI ……………

 

Home address …………………………………………………………………………………………….

 

……………………………………………………………….. Home telephone  (……)…………………

 

IN CASE OF EMERGENCY PLEASE CONTACT

 

Name ……………………………………………………………. Relationship …………………………

 

Address …………………………………………………………………………………………………….

 

……………………………………………………………………..Telephone  (……)……………………

OR

Name ……………………………………………………………. Relationship …………………………

 

Address …………………………………………………………………………………………………….

 

……………………………………………………………………..Telephone  (……)……………………

 

Usual doctor ……………………………………………………. Telephone  (……)….………………..

 

Address……………………………………………………………………………………………………..

 

Other medical specialists ………………………………………Telephone (…….)……………………

 

Address …………………………………………………………………………………………………….

 

Medicare number ………………………………………………Hospital insurance        YES/NO

 

If “yes”, name of insurer ……………………………………… Policy number ……………………….

 

IMMUNISATIONS Please indicate year of immunisation for each of the following:         Polio……… Smallpox……… Typhoid………. Hepatitis….….. Meningococcal….…. Mumps……. Measles……….

 

For Tetanus, please give actual month and year:             …………(m) …………(y)

 

Do you wear glasses? YES/NO Contact lenses? YES/NO Hard/soft   7 day   30 day

 

Do you have dentures/false teeth? YES/NO

 

PLEASE LIST ALL INFORMATION REGARDING THE FOLLOWING:

 

Are you under treatment for any illness or condition? YES/NO If “yes”, please give details:

 

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Are you currently taking any form of medication? YES/NO If “yes”, please give name, dosage and frequency and any side effects.

 

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Do you have any allergies? YES/NO

If “yes”, please give details (foods, bites, stings, medications e.g. penicillin or anaesthetic)

 

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Do you have any disabilities? YES/NO If “yes”, please give details. Note: it may be possible to modify activities to accommodate some disabilities. Please discuss concerns with your leader/s.

 

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Do you have any previous injuries? YES/NO      If “yes”, please give details.

 

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Do you have any history of heart problems? YES/NO      If “yes”, please give details.

 

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Have you ever undergone surgery? YES/NO      If “yes”, please give details.

 

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Please circle each of the following ILLNESSES or CONDITIONS you have had and give the year/s of occurrence.

 

Arthritis                      Diabetes                    Malaria                      Poliomyelitis

Asthma                      Epilepsy                    Measles                     Rheumatic fever

Chicken pox              Gall bladder              Meningitis                   Tuberculosis

Colitis                        Heart disease           Mononucleosis           Typhoid

Convulsions              Hepatitis                    Mumps                       Ulcer

Cystitis                      Jaundice                   Pleurisy                      OTHER

 

Please circle the INJURIES you have had and give the location and year.

 

Back pain                 Concussion                Dislocation                 Fracture

Hernia                       Sprain                        Strain                         OTHER

 

Please circle any of the following CONDITIONS you have had and give the year of occurrence.

 

Blackout                    Dizzy spells                       Headaches                     Menstrual cramp

Chronic cough          GIU tract problem              High blood pressure       Muscle cramp

Chest pain