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    Medical Information Form

    Uploaded by

    Not yet Sense
    This document provides a confidential emergency medical information form to assist medical teams. It requests personal details like name, address, age, medical conditions, allergies, current medications and emergency contacts. The form states that the information will only be used for medical treatment purposes and will remain confidential. It also includes a candidate declaration form for use of a swimming pool facility. This requests health details and swimming experience. The candidate signs to confirm accurate details and a medical staff member inspects and certifies the candidate is free of infections before pool use.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Information Form

    Uploaded by

    Not yet Sense
    125 views2 pages
    This document provides a confidential emergency medical information form to assist medical teams. It requests personal details like name, address, age, medical conditions, allergies, current medications and emergency contacts. The form states that the information will only be used for medical treatment purposes and will remain confidential. It also includes a candidate declaration form for use of a swimming pool facility. This requests health details and swimming experience. The candidate signs to confirm accurate details and a medical staff member inspects and certifies the candidate is free of infections before pool use.

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    Medical Information Form

    Original Title

    Medical Information form

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    This document provides a confidential emergency medical information form to assist medical teams. It requests personal details like name, address, age, medical conditions, allergies, current medications and emergency contacts. The form states that the information will only be used for medical treatment purposes and will remain confidential. It also includes a candidate declaration form for use of a swimming pool facility. This requests health details and swimming experience. The candidate signs to confirm accurate details and a medical staff member inspects and certifies the candidate is free of infections before pool use.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    125 views2 pages

    Medical Information Form

    Uploaded by

    Not yet Sense
    This document provides a confidential emergency medical information form to assist medical teams. It requests personal details like name, address, age, medical conditions, allergies, current medications and emergency contacts. The form states that the information will only be used for medical treatment purposes and will remain confidential. It also includes a candidate declaration form for use of a swimming pool facility. This requests health details and swimming experience. The candidate signs to confirm accurate details and a medical staff member inspects and certifies the candidate is free of infections before pool use.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Confidential Emergency Medical Information Form

    This Document is meant to provide the correct information to Medical Team providing medical
    support. The Medical Information will be conveyed only for treatment purposes and is for assisting
    the Medical Team to have the right information in case of Emergency. THE INFORMATION OF THIS
    FORM WILL REMAIN CONFIDENTIAL.

    Name:
    Address:
    Age:
    Date of Birth:
    Gender:
    Blood Group:

    1. Do you have any Medical Condition(s) which your healthcare provider should be aware of?
     Yes  No
    If yes, Give details:
    ………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………..
    2. Do you have any known allergies?
     Yes  No
    If yes, Give details:
    ………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………..
    3. Are you currently on any medication?
     Yes  No
    If yes, Give details:
    ………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………….
    4. Name and contact number of your own doctor:
    ………………………………………………………………………………………………………………………………………………
    5. Person to be contacted in Emergency:
    Name: ……………………………………………………………………………………………………………………………………
    Relationship: …………………………………………. Contact No. ……………………………………………………......

    I acknowledge that the information provided in this form will be meant only for Medical
    Treatment purposes and in the event of Medical Emergency.

    Signed:
    Dated:
    Department of SPORTS

    For Use of Swimming Pool Facility(Version1.4)

    Candidate Name: ……………………………………………………………………………


    Paste you photo here
    Age:
    Gender:
    Height(cm):
    Weight(Kg):

    Declaration by Candidate of Following Details:

    1. Any history of Epilepsy(fits), Dizziness, Asthma, TB, Allergy, Venereal Disease: Yes/No
    2. History of Water phobia: Yes/ No
    3. History of Diabetes, Heart Problems: Yes/ No
    4. Have you ever swum in swimming pool/river/lake etc.? Yes/No

    Undertaking by Candidate:

    I, Mr/Ms …………………………………………………………………… have submitted correct details above.

    Candidate Signature: …………………………….

    Candidate is inspected for Infections/ Communicable diseases:

    Heart Rate (per minute):


    Blood Pressure (S/D mm of Hg):
    1. Skin Infection
    2. Eye
    3. Ear
    4. Throat
    I hereby certify that I have examined Mr/Ms ………………………………on date …………… time……………. and
    on inspection he is found to be free of communicable diseases.

    Medical Staff Signature:


    Name of Staff:
    Date:

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