Sa murray 200 / 100 / relay challenge medical information form

Riverland Paddling Marathon Events - MEDICAL INFORMATION FORM

NAME: Surname: ………………………………….……………… Given / Preferred Name: …………………………………………………….
HOME ADDRESS: ……………………………………….…………………………………………………………………………………………….
Suburb/Town: ……………………………………………………………….…. State: ….……. Postcode: ………………. CONTACT: Telephone: …………………….………………. Home or Business (please circle) Mobile: ….………………………………………. PERSONAL: Date of Birth: …………/…………/…………. Age at Race ……………. Gender: Male □ Female □
Medicare Number: ……………………………….……… Private Health Insurance: …………………………………. Private Health Ins Number: ……………………….………………. Ancillary Benefits Cover: YES / NO (please circle) Ambulance Ins Number: ………….…….………………………….
EMERGENCY USE: Details of a person who can be contacted during the Riverland Paddling Marathon Events.
NAME: …………………………………………………. Relationship: ………………………………………………………
ADDRESS: ……………………………………………………
Suburb: ………………………………………………………. Postcode: ……………………….
Contact Phone: ……………………………………………… Mobile: ………………………………………….
MEDICAL CONTACTS:
Name and address of family doctor or clinic: …………………………………………………………………………………………………….……
………………….………………………………………… Phone: ………………………………….
Name and address of any relevant specialist: …………………………………………………………………………………………………….……
………………….………………………………………… Phone: ………………………………….
HEALTH STATEMENT
Each paddler shall disclose any chronic or recurrent ailment, allergy or physical incapacity suffered for the purpose of medical support staff preparedness. Does the paddler suffer from any physical or other disabilities? If YES, please specify: …………………………………………….…………… …………………………………………………………………………………… Explanation / Medication: ……………………………………………………… Diabetes? ……….…… Type 1 / Type 2 …………………………………………………………………………………… …………………………………………………………………………………… Dizzy spells or Blackouts? ……………. Heart Disease? …………………………. …………………………………………………………………………………… High Blood Pressure? …………………. …………………………………………………………………………………… Does the paddler have any known
allergies? i.e. Penicillin, bee stings,
If YES, please specify: ……………………………………………….………… insects, hay fever, food (including nuts),
…………………………………………………………………………………… drug, other environment related allergy.
Does the paddler carry with them any medications while paddling? i.e. Name of Drug: ………………………………………………….……………. injection/tablet/capsule, Insulin, Ventolin, other Drugs. Dosage: ……………………………………………………………….………. Reason or Cause: ……………………………………………….……………… How Often Administered: ………………………………….…………………. Administered by Whom: …………………………………….………………… any further information you
If YES, please specify: ………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… Year of Last Booster injection: ……………………
I hereby Authorise the Race Director of the Riverland Paddling Marathon Events, in circumstances where it is not possible or it is impracticable to communicate with me,
to seek for me or the person named on this form, such Surgical, Medical or Dental treatment as a qualified Surgeon, Medical or Dental Practitioner may consider to be
necessary (including the transfusion of blood) and I hereby Consent to such treatment.
Signed: ………………………………………………. (to be signed by Parent or Guardian for paddlers under 18 years of age) Date: …………………………….
Please complete a separate medical declaration form for each paddler entered (photocopy extra forms as required). Fold into thirds and seal with tape or a staple. Send it to us with your entry form. No paddler is entitled to start in the named events without having first submitted this form completed. This important information that shall be treated as CONFIDENTIAL and will remain with the race doctor for the duration of the events. All medical information will be destroyed after the events. Please fold in thirds with this side out and secure at top with tape or staple Confidential Medical Information
Paddlers Name: …………………………………………………………………………………………………. Please fold in thirds with this side out and secure at top with tape or staple PLEASE NOTE
All Paddlers MUST complete a Medical History form before your entry will be
accepted.

Source: http://www.paddlesportssa.com.au/media/1231/Medical%20History%20Form.pdf