The Adelaide Swords Club Inc

Reviews
Shared by: gabyion
Stats
views:
1
rating:
not rated
reviews:
0
posted:
11/16/2009
language:
English
pages:
0
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: / /

Related docs
INTRODUCTION TO ADELAIDE
Views: 8  |  Downloads: 0
KIWANIS ADELAIDE NEWS
Views: 3  |  Downloads: 0
RUSSELL SWORDS
Views: 6  |  Downloads: 0
Great swords
Views: 28  |  Downloads: 0
Fraternal Swords
Views: 195  |  Downloads: 0
Snapshot _Swords_
Views: 3  |  Downloads: 0
Adelaide
Views: 10  |  Downloads: 2
premium docs
Other docs by gabyion
VERIFICATION AND LICENSING CRITERIA
Views: 4  |  Downloads: 0
UU Fellowship of Visalia
Views: 7  |  Downloads: 0
Using Water Wisely
Views: 5  |  Downloads: 0
Using Graywater for Landscape Irrigation
Views: 3  |  Downloads: 0
Use your Common Cents Wisely
Views: 5  |  Downloads: 0
USB Meeting Summary
Views: 5  |  Downloads: 0
USA Exports of Wood _ Chips_ etc
Views: 5  |  Downloads: 0
US RoHS Presentation
Views: 15  |  Downloads: 0
Uptons Curbside Pickup Program
Views: 3  |  Downloads: 0
Updates
Views: 6  |  Downloads: 0
UNIVERSITY OF ROCHESTER
Views: 5  |  Downloads: 0
University of Florida
Views: 5  |  Downloads: 0
United Illuminating
Views: 6  |  Downloads: 0
Unit 5
Views: 4  |  Downloads: 0