Thank you for filling the form.
Entries limit is exceeded! Please contact your administrator.
"Sorry! User can't post a new entry"
Space limit is exceeded! Please contact your administrator.
"Sorry! User can't post a new entry"
Plan is expired! Please contact your administrator.
"Sorry! User can't post a new entry"
Player Medical Fitness Form
Please fill out the form
1
Step 1
2
Step 2
*
Player Name:
*
First Name
*
Last Name
This field is required.Please enter value
This field is required.Please enter value
Mobile No:
This field is required.Please enter value
Invalid phone number.
The value must be less than or equal to 20
Email id:
This field is required.Please enter value
Please enter valid email address
Player Date of Birth:
This field is required.Please enter value
Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Age:
This field is required.Please enter value
The value allows only numbers
Invalid number!
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
*
Health card number (and province if not Ontario):
This field is required.Please enter value
*
Emergency contact name:
This field is required.Please enter value
Please list any allergies - medication, food, pollen, etc:
This field is required.Please enter value
*
Have you had in the past or do you currently have any of the following: (check any that apply):
Anemia
Asthma
Diabetes
Epilepsy/Seizures
Fainting Spells
Heart Disease
Heart Attack
High Blood Pressure
Kidney Disease
Liver Disease
This field is required.Please enter value
If you answered to any of the above, please provide details you feel are relevant:
This field is required.Please enter value
If you currently have asthma: is it sport induced, do you have a puffer, and what medication is in your puffer:
This field is required.Please enter value
Please list any medications, prescription or non-prescription, that you take regularly:
This field is required.Please enter value
Next
Please list any previous sports injuries, approximate dates, and whether or not it is still a problem:
This field is required.Please enter value
*
Do you have a family history of heart disease or stroke:
Yes
No
This field is required.Please enter value
*
Do you have all of your paired organs (kidneys, lungs, eyes, etc):
Yes
No
This field is required.Please enter value
If you do not have all your paired organs, what are you missing:
This field is required.Please enter value
Have you ever (to your knowledge) had a concussion/concussions:
Yes
No
This field is required.Please enter value
If you have had a concussion or concussions, please list the date(s) and circumstance(s) as accurately as possible:
This field is required.Please enter value
Are your pupils the same size:
Yes
No
This field is required.Please enter value
Please share any other details you feel are relevant:
This field is required.Please enter value
Do you consent to have this information shared with the University of Ottawa Quidditch coaches, and if necessary, on-field medical personnel, EMT's, or hospital staff:
Yes
No
This field is required.Please enter value
Comments:
This field is required.Please enter value
Previous
Submit