The Adelaide Swords Club Inc.
HEALTH INFORMATION 2007-2008
Member: SURNAME: G.P. NAME: G.P. TELEPHONE: AMBULANCE COVER: YES / NO
_________GIVEN NAMES: _____________________________ ___________________
G.P. ADDRESS:____________________________________________________________________
CHECKLIST (if yes, describe next to category) Y/N Y/N Y/N Y/N Y/N Abnormal Blood Pressure Cardiovascular Condition Respiratory Condition Diabetes Hearing Impairment Y / N Neurological Condition Y / N Epilepsy Y / N Joint Surgery Y / N Visual Impairment Y / N Contagious Diseases
CURRENT MEDICATIONS:(inc. asthma medication) If more space needed please attach separate page. Medication Name Condition Taken For Known Relevant Side Effects
Is there any other significant medical history or relevant information that may affect treatment in an emergency situation or preclude involvement in any activity (including joint problems)?
This form is confidential and will only be used to assist in a medical emergency. As a member of The Adelaide Swords Club Inc I understand that it is my responsibility to complete this form annually and / or if there is any change to my health status. (If under 18 years of age, this form must be signed by a parent / guardian) Printed Name: __ Signature: _____ Date: / /