OMHA Medical Information Sheet

OMHA Medical Information Sheet
This information will be use by the Team Safety. This will help the Safety Person assist players should they become ill or injured. This form also authorizes them to seek emergency medical attention for a player if they are injured in a practice/game and their parent/guardian isn't present or can't be reached. Complete this form with all the details that match your child's medical file.
Player Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Street Address
Street Address Line 2
CityProvince
Postal Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Provincial Health Care Number
(Optional)

Parent/Guardian & Emergency Contact Information
Mother's Name
First NameLast Name
Father's Name
First NameLast Name
Mother's Business Number
Format: (000) 000-0000.
Father's Business Number
Format: (000) 000-0000.
Alternate Emergency Contact (If parents/guardians are not available)
First NameLast Name
Telephone
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityProvince
Postal Code

Medical Information
Doctor's Name
Telephone
Format: (000) 000-0000.
Dentist's Name
Telephone
Format: (000) 000-0000.
* Before a player participates in a hockey program, any medical condition or injury problem should be checked by that individual's family physician.
Date of last completed physical examination:
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Medications:
If none, enter N/A
Allergies:
If none, enter N/A
Recent Injuries:
If none, enter N/A
Any Information not covered above:
If none, enter N/A
Date:
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Parent or Guardian:
Clear
By signing you agree to the conditions stated above
Should be Empty:

Rows	Yes	No
Previous history of concussions
Fainting episodes during exercise
Epileptic
Wear glasses
Are lenses shatterproof
Wears contact lenses
Wears dental appliance
Hearing problem
Asthma
Trouble breathing during exercise
Heart Condition
Medication
Allergies
Has any health problem that would interfere with participation on a hockey team
Has an illness that lasted more that a week and required medical attention in the past year
Has had injuries requiring medical attention in the past year
Has been admitted to hospital in the last year
Surgery in the last year
Hepatitis B vaccination

Parent/Guardian & Emergency Contact Information