Annual Medical Examination form for IMMAF Competitors Please book a medical examination with your doctor and take a printed copy of this form with you. Once completed, please return all 5 pages (along WITH a copy of your blood test results, IF their interpretation is included) to your team Medical Safety Lead, in accordance with their instructions. Competitor Name: National team: Medical ID Number (if applicable): Date of birth: Telephone number: Email address: Postal address: Name of Examining Doctor: Qualifications: Doctor Registration Number: Practice address: Telephone number: Email address: PAST MEDICAL HISTORY Any hospital admission for medical or surgical reasons? Yes! No! Date Summary Current Status SafeMMA Annual Medical Examination form for IMMAF Competitors, August 2016 version, Page 1
Allergies? Yes! No! Allergen Reaction Hospitalisation Treatment Medications? Yes! No! Name Dose/Frequency Reason Has anyone in the family died below the age of 40 due to a heart condition? Yes! No! Relative Summary of medical conditions Age of Death Examination normal? Yes! No! Height (cm) Weight (kg) Heart Rate Systolic BP Diastolic BP Additional weight information as reported by fighter: Yes! No! Normal/Walk around weight (kg) Weight category for competition (kg/lbs) SafeMMA Annual Medical Examination form for IMMAF Competitors, August 2016 version, Page 2
EYES Pupil: reacting to light Right: Yes! No! Pupil: reacting to light Left: Yes! No! Fundi: Right normal? Yes! No! Fundi: Left normal? Yes! No! Visual acuity Right: /6 Visual acuity Left: /6 EARS/NOSE/THROAT Tympanic Membrane Right normal? Yes! No! Tympanic Membrane Left normal? Yes! No! Hearing: Right normal? Yes! No! Hearing: Left normal? Yes! No! Teeth: Note condition: Normal? Yes! No! NECK Movements full and pain free? Yes! No! SafeMMA Annual Medical Examination form for IMMAF Competitors, August 2016 version, Page 3
CHEST Rib cage normal? Yes! No! Lungs normal? Yes! No! Heart Sound: Regular? Yes! No! Murmurs? Yes! No! Apex: Mid clavicular line 5 th intercostal space? Yes! No! ABDOMEN Scars? Yes! No! Enlarged liver or spleen? Yes! No! BACK Is movement of the back normal? Yes! No! LIMBS Are movements of the limbs normal? Yes! No! Hands and wrists normal? Yes! No! SafeMMA Annual Medical Examination form for IMMAF Competitors, August 2016 version, Page 4
NERVOUS SYSTEM Any tremor? Yes! No! Romberg test +? Yes! No! Coordination normal? Yes! No! BLOOD TEST RESULTS *tick here if NOT interpreting blood test results! NOTE TO DOCTOR: Please counsel all competitors prior to arranging phlebotomy. Interpretation must be accompanied by copies of laboratory results sent back with this form. HEPATITIS B Neg. surface antigen (HBsAg) test required HEPATITIS C HIV MUST inc. P24 antigen and HIV 1+2 antibodies CONCLUSION I confirm that there are no problems found as specified in this medical examination: Yes! No! Signed (Doctor): Print name: Date of examination: SafeMMA Annual Medical Examination form for IMMAF Competitors, August 2016 version, Page 5