ࡱ> *,'() bjbj 4.4"; 8-e#e#e#e#@$%|%@l,n,n,n,n,n,n,${/2J,%@$@$%%,e#e#-+++%e#e#l,+%l,+++e#ۤf&+X,-0-+g2\'g2++,g2+%%+%%%%%,,B*f%%%-%%%%g2%%%%%%%%% :  Diver s Annual Medical Form 2010  All information will be kept CONFIDENTIAL within the Medical Team Section 1: Contact Details of Diver Surname: FORMTEXT      First and middle names: FORMTEXT      Female/Male (please check):Male  FORMCHECKBOX  / Female  FORMCHECKBOX Date of Birth: FORMTEXT      Address: FORMTEXT      Tel:Home:  FORMTEXT       Work:  FORMTEXT       Cell:  FORMTEXT      Email: FORMTEXT       Parent / Guardian / Next of KinRelationship to Diver: FORMTEXT      Surname: FORMTEXT      First and middle names: FORMTEXT      Female/Male (please check):Male  FORMCHECKBOX  / Female  FORMCHECKBOX Date of Birth: FORMTEXT      Address: FORMTEXT      Tel:Home:  FORMTEXT       Work:  FORMTEXT       Cell:  FORMTEXT      Email: FORMTEXT       Parent / Guardian / Next of KinRelationship to Diver: FORMTEXT      Surname: FORMTEXT      First and middle names: FORMTEXT      Female/Male (please check):Male  FORMCHECKBOX  / Female  FORMCHECKBOX Date of Birth: FORMTEXT      Address: FORMTEXT      Tel:Home:  FORMTEXT       Work:  FORMTEXT       Cell:  FORMTEXT      Email: FORMTEXT       Section 2: Please list any medical problems and/or injuries you have experienced over the last 12 months (include ALL current conditions and all problems  minor or  major ):  FORMTEXT       Section 3: Please list ALL medicines that you are currently taking (include ALL pills, sprays, drops, inhalers, creams, patches, injections, suppositories, etc.):  FORMTEXT       Section 4: Please list any TUEs (Therapeutic Use Exemptions) Indicate if  applied for or  already granted:  FORMTEXT       Section 5 Please list ALL vitamins and/or supplements you are currently taking:  FORMTEXT       Section 6: Family Medical History  please list any conditions which occur in your immediate family (e.g. diabetes, heart disease, asthma, bleeding disorders..& .):  FORMTEXT       Section 7: Immunizations  please indicate whether you are immunized against the following: Tetanus/Diptheria:Yes  FORMCHECKBOX  / No  FORMCHECKBOX Date of Last Immunization: FORMTEXT      Hepatitis A:Yes  FORMCHECKBOX  / No  FORMCHECKBOX Date of Last Immunization: FORMTEXT      Hepatitis B:Yes  FORMCHECKBOX  / No  FORMCHECKBOX Date of Last Immunization: FORMTEXT      Flu Shot:Yes  FORMCHECKBOX  / No  FORMCHECKBOX Date of Last Immunization: FORMTEXT      Typhoid:Yes  FORMCHECKBOX  / No  FORMCHECKBOX Date of Last Immunization: FORMTEXT       Section8: Allergies  please indicate whether you have any known allergies, especially to any medicines:  FORMTEXT       Section 9: Dietary Requirements  please indicate any specific dietary requirements:  FORMTEXT       Section 10: Musculoskeletal System: Do you have an problems with your Neck?Yes  FORMCHECKBOX  / No  FORMCHECKBOX  Shoulders?Yes  FORMCHECKBOX  / No  FORMCHECKBOX  Back?Yes  FORMCHECKBOX  / No  FORMCHECKBOX  Knees?Yes  FORMCHECKBOX  / No  FORMCHECKBOX  Wrist? Yes  FORMCHECKBOX  / No  FORMCHECKBOX Please detail: FORMTEXT       Section 11: Eyes: Do you wear Glasses?Yes  FORMCHECKBOX  / No  FORMCHECKBOX Do you wear contacts?Yes  FORMCHECKBOX  / No  FORMCHECKBOX Any problems with your eyes? (e.g. squint, glaucoma, cataract) FORMTEXT       Section 12: Teeth: Do you have any current problems?Yes  FORMCHECKBOX  / No  FORMCHECKBOX If Yes, please detail FORMTEXT      Do you have any loose teeth,false teeth, caps, crowns?Yes  FORMCHECKBOX  / No  FORMCHECKBOX If Yes, please detail FORMTEXT       Section 13: Do you Smoke? Do you smoke?Yes  FORMCHECKBOX  / No  FORMCHECKBOX If Yes, maximum ever smoked per day FORMTEXT       Cigarettes  FORMCHECKBOX / Cigars  FORMCHECKBOX  Section 14: Do you use recreational drugs? Do you use recreational drugs (e.g. marijuana)Yes  FORMCHECKBOX  / No  FORMCHECKBOX If Yes, do you use themRarely  FORMCHECKBOX  / Occasionally  FORMCHECKBOX  / Regularly  FORMCHECKBOX  I declare that the information I have provided is complete and accurate. Divers Signature ______________________Date __________________________ ****For Divers under 18 ONLY (signature of parent/guardian) **** Signed__________________________________ Date: _______________ Name  FORMTEXT       Relationship FORMTEXT       Parent FORMCHECKBOX  /Guardian FORMCHECKBOX  (please check) To be cBFHL 0 2 ֻw_J4+h`\h ;CJOJQJ\^JaJmH sH (h`\h ;CJOJQJ^JaJmH sH .h&Mh ;5CJOJQJ\^JaJmH sH &h&MhZ5OJQJ\^JmH sH .h&MhZ5CJOJQJ\^JaJmH sH /h%5>*CJ KH$OJQJ\^JaJ mH sH 5h`\hZ5>*CJ KH$OJQJ\^JaJ mH sH h`\hZCJaJmH sH h`\hZmH sH jh`\hZUmH sH  HJLN 2 Z yy $IfgdZgdZTkd%6$$Ifl0$ t644 layt`\$$$@&Ifa$gd`\ $IfgdZ $$Ifa$gd`\ 2 4 H J L V X \    . 0 L ѵcG7j-8h`\h ;CJOJQJU^JaJmH sH 7jY7h`\h ;CJOJQJU^JaJmH sH +h`\h ;CJOJQJ\^JaJmH sH ?jh`\h ;CJOJPJQJU^JaJmHnHo(sH u7j6h`\h ;CJOJQJU^JaJmH sH (h`\h ;CJOJQJ^JaJmH sH 1jh`\h ;CJOJQJU^JaJmH sH Z \ R NTkd7$$Ifl0$| t644 layt`\ $IfgdZTkd6$$Ifl0$| t644 layt`\L N P R T r t ʵʵcʵJ5(h`\h%CJOJQJ^JaJmH sH 1jh`\h%CJOJQJU^JaJmH sH ?jh`\h ;CJOJPJQJU^JaJmHnHo(sH u7ju9h`\h ;CJOJQJU^JaJmH sH +h`\h ;CJOJQJ\^JaJmH sH (h`\h ;CJOJQJ^JaJmH sH 1jh`\h ;CJOJQJU^JaJmH sH 7j8h`\h ;CJOJQJU^JaJmH sH R T r NTkd9$$Ifl0$| t644 layt`\ $IfgdZTkd9$$Ifl0$| t644 layt`\     & ( < ʪʕfJf*ff?jh`\h ;CJOJPJQJU^JaJmHnHo(sH u7j;h`\h ;CJOJQJU^JaJmH sH 1jh`\h ;CJOJQJU^JaJmH sH +h`\h ;CJOJQJ\^JaJmH sH (h`\h ;CJOJQJ^JaJmH sH ?jh`\h%CJOJPJQJU^JaJmHnHo(sH u1jh`\h%CJOJQJU^JaJmH sH 7jI:h`\h%CJOJQJU^JaJmH sH   N NTkdy<$$Ifl0$| t644 layt`\ $IfgdZTkd:$$Ifl0$| t644 layt`\< > @ J L \ ^ r t v ʪʕʕyʪʕcʕGʪʕc7j<h`\h ;CJOJQJU^JaJmH sH +h`\h ;CJOJQJ\^JaJmH sH 7j<h`\h ;CJOJQJU^JaJmH sH (h`\h ;CJOJQJ^JaJmH sH ?jh`\h ;CJOJPJQJU^JaJmHnHo(sH u1jh`\h ;CJOJQJU^JaJmH sH 7j;h`\h ;CJOJQJU^JaJmH sH    2 Z ]Q $$@&Ifgd ;@kd=$$If%t%t%622 l4a $Ifgd ;gdZTkdM=$$Ifl0$| t644 layt`\  2 4 H J L V X n p Ѽ郡eGe:j>h&Mh ;CJOJQJU\^JaJmH sH ;jh&Mh ;CJOJPJQJU\^JaJmH o(sH :j>h&Mh ;CJOJQJU\^JaJmH sH 4jh&Mh ;CJOJQJU\^JaJmH sH (h&Mh ;CJOJQJ^JaJmH sH .h&Mh ;5CJOJQJ\^JaJmH sH +h&Mh ;CJOJQJ\^JaJmH sH Z \ n DSkd_?$$If0%|t%622 l4a $$@&Ifgd ; 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YES / NO (please circle) ANNUAL MEDICAL SCREEN REVIEWED? MD Signature Date FURTHER INVESTIGATIONS RECOMMENDED: THERAPEUTIC USE EXEMPTION (TUE) NEEDED? YES / NO (please circle) COMPLETED YES / NO (please circle) Signature Date FIT FOR TRAVEL, TRAINING AND COMPETITION Signature Date NAME FORMTEXT       Contact Details of your Sport Science and Medicine Providers Please provide contact details of all the Sport Science and Medicine Providers that support you at Local and/or Regional Level. General Practitioner s (GP s) contact details: Name:  FORMTEXT       Address: FORMTEXT       Tel: FORMTEXT       (Work) Email:  FORMTEXT        Local / Regional Sports Medicine Doctor (provide details if you use, or have used, a Sports Doctor): Name:  FORMTEXT       Address: FORMTEXT       Tel: FORMTEXT       (Work) Email:  FORMTEXT        Local Physiotherapist (please provide details of the Physiotherapist(s) you have used, or would wish to use, local to you): Name:  FORMTEXT       Address: FORMTEXT       Tel: FORMTEXT       (Work) Email:  FORMTEXT        Other Medical Experts (ie. Consultant / Specialist / Surgeon): Name:  FORMTEXT       Address: FORMTEXT       Tel: FORMTEXT       (Work) Email:  FORMTEXT        Sport Massage Therapist (please provide details of the Massage Therapist(s) you have used, or would wish to use, local to you): Name:  FORMTEXT       Address: FORMTEXT       Tel: FORMTEXT       (Work) Email:  FORMTEXT        Strength & Conditioning Coach (please provide details of the S&C coach you have used, or would wish to use, local to you): Name:  FORMTEXT       Address: FORMTEXT       Tel: FORMTEXT       (Work) Email:  FORMTEXT        Other Local / Regional Sport Science / Medicine Provider (i.e. psychologist, dietician, physiologist, biomechanists) Name:  FORMTEXT       Address: FORMTEXT       Tel: FORMTEXT       (Work) Email:  FORMTEXT        Other Local / Regional Sport Science / Medicine Provider (i.e. psychologist, dietician, physiologist, biomechanists) Name:  FORMTEXT       Address: FORMTEXT       Tel: FORMTEXT       (Work) Email:  FORMTEXT   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