Player Medical History

Please note that this is not a release of liability or waiver of any sort. This is a form to help the coaches of the University of Ottawa Quidditch Team better handle any future injury you may incur while playing the sport of quidditch. It is necessary that this information is shared with medical professionals in the event of a serious on-pitch injury. This information will also help the coaches understand any medical problems you may have, whether it's asthma or a heart condition. Within the team, the only people who will have access to this information are the coaches.

If you have any questions regarding the completion of this form, please contact either coach of the University of Ottawa Quidditch Team.

Player Name*

First NameLast Name

Player Birth Date*

MonthDayYear

Health card number (and province if not Ontario)*

Emergency contact name

Emergency contact phone number

Please list any allergies - medication, food, pollen, etc

If you have an epi-pen, please note that and where you keep it.

Have you had in the past or do you currently have any of the following: (check any that apply)

If you answered yes to any of the above, please provide details you feel are relevant.

If you currently have asthma: is it sport induced, do you have a puffer, and what medication is in your puffer?

Please list any medications, prescription or non-prescription, that you take regularly.

Please include multivitamins, contraceptives, nutritional supplements, naturopathic medications, etc.

Please list any previous sports injuries, approximate dates, and whether or not it is still a problem.

Do you have a family history of heart disease or stroke?

YesNo

Do you have all of your paired organs (kidneys, lungs, eyes, etc)?

YesNo

If you do not have all your paired organs, what are you missing?

Have you ever (to your knowledge) had a concussion/concussions?

YesNo

If you have had a concussion or concussions, please list the date(s) and circumstance(s) as accurately as possible.

Are your pupils the same size?

YesNo

Please share any other details you feel are relevant.

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

UOttawa Quidditch Player Medical History