KINGSTON-BELLEVILLE FC ("K.B.F.C.")
PRO SOCCER ACADEMY
ATHLETE'S MEDICAL INFORMATION
Name:_______________________________________________________________________
Date of birth: Day ___________ Month ___________ Year ___________
Address:_____________________________________________________________________
Postal Code: _______________ Telephone: ( ____ ) _______________________
Provincial Health Number (optional):
__________________________________________________________
Mother’s Name: _______________________Father’s Name:____________________________
Contact Telephone Numbers: Mother _____________________ Father __________________
Alternate emergency contact (if parents are not available)
Name: _______________________________________ Telephone: _____________________
Address: ____________________________________________________________________
Doctor’s Name: _______________________________ Telephone: (____) _______________
Dentist’s Name: _______________________________Telephone: (____) _______________
Date of last complete physical examination: _________________________________________
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Previous history of concussions
Fainting episodes during exercise
Epileptic
Wears glasses
Are lenses shatterproof
Wears contact lenses
Wears dental appliance
Hearing problem
Asthma
Trouble breathing during exercise
Heart Condition
Diabetic – Type 1_____ Type 2_______
Medication
Allergies
Wears a medical information bracelet or necklace
For what purpose? ____________________________________________________________
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Has any health problem that would interfere with participation on a soccer team
Has had an illness that lasted more than a week and required medical attention
in the past year
Has had injuries requiring medical attention in the past year
Has been admitted to hospital in the last year
Surgery in the last year
Presently injured. Injured body part: ________________
Vaccinations up to date
Hepatitis B vaccination
Give details if you answered “Yes” to any of the above. Use separate sheet if necessary
____________________________________________________________________________
____________________________________________________________________________
Medications: _________________________________________________________________
Allergies: ____________________________________________________________________
Medical conditions: ____________________________________________________________
Recent injuries: _______________________________________________________________
____________________________________________________________________________
Any information not covered above: _______________________________________________
____________________________________________________________________________
Date: ____________________Signature: ___________________________________________