High Performance: Elite Athlete Medical Form - 2022/23
Name
*
Name
First
First
Last
Last
Squad
*
u18
All-Abilities
Opens
Seniors
Role
*
Player
Coach
Team Manager
Phone
*
Date of Birth
*
Address
*
Address
Address
Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Are you of Aboriginal and/or Torres Strait Islander origin?
*
Yes
No
Prefer not to say
Consent
Please agree to the following statements regarding the collection and use of infomation collected via this form.
By completing this form, I consent to the collection of this information by Bowls SA for the purposes of medical treatment at Bowls SA tournaments, events or programs in accordance with the provisions of the Privacy Act 1988 (Cth).
*
I agree
I understand and agree that Bowls SA may only use or disclose this personal information to third parties, including approved Bowls SA engaged coaches/team managers/event providers for the purpose of my duty of care, OR to emergency service providers, for the purposes of medical treatment or any other directly related purpose.
*
I agree
I don't agree
Further I understand that if I do not supply any or all of the required information it will impact on the provision and effectiveness of any medical treatment rendered to me if required.
*
I understand
For athletes under the age of 18, as the athlete's parent/guardian, I agree to the above statements and have provided the following information on their behalf
Not applicable
I agree
Name of parent/guardian completing this form on behalf of the athlete ( Only applicable to athletes under 18 years of age)
Name of parent/guardian completing this form on behalf of the athlete ( Only applicable to athletes under 18 years of age)
First
First
Last
Last
General Medical History
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Please provide details regarding your general health history
Do you suffer from any illness or disease, which Bowls SA should be aware of?
*
Yes
No
If yes, please specify:
If yes, please specify:
Have you ever suffered from, or do you now suffer from, any of the following:
*
Heart disease or heart surgery
Chest pain, angina or tightness in chest
High blood pressure
Asthma, bronchitis or other lung diseases/problems
Disease or disorder of the nervous system
Blackouts, fainting, fits or epilepsy
Psychiatric illness
Depression, anxiety or other Mental Health condition
Diabetes
Fractures or dislocations
Arthritis or rheumatism
Dermatitis, eczema or other skin problems
Smoker
None
(Please select the most appropriate response)
Do you have any disability or dimension of restricted access?
Physical - Mobility- requiring the use of a power wheelchair or scooter
Physical - Mobility- requiring the use of a manual wheelchair
Physical - Mobility- requiring the use of other mobility aids
Physical - Mobility- no aid required but able to cover a limited distance or cannot manipulate objects
Physical- not affecting mobility or dexterity
Sensory - Blind or vision
Sensory - Deaf or hearing
Sensory & Developmental – Autism Spectrum Disorder
Intellectual - involving issues of speech, understanding, learning or retaining information
Other (please specify)
Other (please specify)
(Please select the most appropriate response)
Is there anything Bowls SA can do to assist?
Yes
No
If yes, please specify:
If yes, please specify:
Is there any medical condition not mentioned above which may require treatment, now or in the future, of which Bowls SA should be aware?
*
Yes
No
If yes, please specify:
If yes, please specify:
For example, DNR requirements, blood transfusion
Are you currently taking any prescribed medication?
*
Yes
No
If yes, please provide details:
If yes, please provide details:
Do you carry any medication in case of an emergency?
*
Glucose
Inhaler
Epi-Pen
Angina medication
Other
Other
No
Please supply date of last anti-tetanus injection:
Allergies and Dietary Requirements
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Please provide details regarding any allergies or dietary requirements.
Are you allergic to any medication?
*
Yes
No
If yes, please specify:
If yes, please specify:
Do you have any dietary requirements?
*
Gluten Free
Dairy Free
Vegetarian
Vegan
Allergy - Nuts
Allergy - Nuts
Allergy - Other
Allergy - Other
None
Other
Other
Do you have any other allergies Bowls SA should be aware of
*
Yes
No
If yes, please specify:
If yes, please specify:
Injury History
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Please provide details regarding any current or historical injuries.
Are you suffering from any injury, for which you are currently receiving treatment, or for which you may require treatment, during the next 12 months?
*
Yes
No
If yes, please specify:
If yes, please specify:
Do you have any recurring injury Bowls SA may need to be aware of?
*
Yes
No
If yes, please specify:
If yes, please specify:
Please provide any further details of your health or injury status which Bowls SA needs to be aware of:
Medical & Allied Health Providers
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Name of your GP:
*
Name of your GP:
First
First
Last
Last
Practice Name
*
Phone
*
Medicare Number
*
Do you have Private Health Hospital Cover
*
No
Yes, with:
Yes, with:
Do you have Ambulance Cover:
*
No
Yes - as part of my private health
Yes - standalone cover
Do you access any of the following allied health providers or treatments for the purpose of improving your sports performance?
Physiotherapy
Chiropractor
Sports massage
Osteopath
Acupuncture/Dry needling
Dietitian
PT/Trainer
Other
Other
Emergency Contact Details
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Name of Emergency Contact 1
*
Name of Emergency Contact 1
First
First
Last
Last
Relationship to athlete
*
Phone
*
Name of Emergency Contact 2
*
Name of Emergency Contact 2
First
First
Last
Last
Relationship to athlete
*
Phone
*
If you are human, leave this field blank.
Submit