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2023 World Abilitysport Games Medical Form

2023 World Abilitysport Games
Medical Form

All athletes and staff that are a part of the Move United delegation going to the 2023 World Abilitysport Games should complete the below medical form. When you hit submit, you will receive a confirmation email. Do not close out of this webpage until you receive a confirmation. If you do not receive a confirmation then you missed a required question. Please go back and check your responses and then try to submit again.

Step 1 of 2

Participant Name(Required)

First Last

Participant Email(Required)

Parent/Guardian Email (if under 18)

Participant Date of Birth(Required)

Participant Role(Required)

Insurance Information

Medical Insurance Company(Required)

Medical Insurance Policy Number(Required)

Medical Insurance Policy Holder(Required)

Dental Insurance Company

Dental Insurance Policy Number

Dental Insurance Policy Holder

Medical Background

Gender(Required)

Do you have a disability?(Required)

Disability Diagnosis(Required)

Disability is...(Required)

Treatment History, if any(Required)

Do you have any known allergies?(Required)

Please list any known allergies(Required)

What are your symptoms of an allergic reaction?(Required)

Please list current medications. If none, write N/A.(Required)

Past Surgeries. If none, write N/A.(Required)

Do you have asthma?(Required)

Do you carry an inhaler?(Required)

Do you have a shunt?(Required)

Have you ever had a shunt malfunction?(Required)

What were the symptoms of your shunt malfunction?(Required)

Have you ever had a tethered spinal cord?(Required)

What were the symptoms?(Required)

Have you ever had a concussion and/or TBI?(Required)

Describe the incident.(Required)

Do you have any history of seizures?(Required)

What are your seizure triggers?(Required)

How often do you have a seizure?(Required)

How do you manage your seizures?(Required)

Do you have any history of heart disease, heart murmurs, or high blood pressure?(Required)

Has anybody in your family had a sudden death or heart attack before the age of 50?(Required)

Have you ever been dizzy or passed out with exercise?(Required)

Please describe any history of fractures, strains, and/or sprains.

Do you have scoliosis?(Required)

Have you had a back fusion?(Required)

Do you have any organs missing?(Required)

What organs are missing?(Required)

Do you wear

Glasses

Contact Lenses

Hearing Aids

Dental Appliances

What type of bladder management do you use?(Required)

If other, please specify.(Required)

Have you had any recent bladder infections? (Last 3 months)(Required)

Do you have any history of pressure ulcers requiring surgery?(Required)

Please list date(s) of surgery.(Required)

Do you have any current pressure sores?(Required)

Where are they and how are you treating them?(Required)

Do you have any issues with(Required)

Overheating

Dysreflexia

Spasticity

Pain

None of the above

Date of Last Tetanus Shot(Required)

Any other health concerns you would like us to know about?