2025 Season Medical Form
Your Name *
Your Email *
Player cell # *
Home Address (incl. postal code) *
Alberta Health Care Number *
Date of Birth *
PRIMARY Emergency Contact Details - incl. cell phone # *
Relationship to you *
SECONDARY Emergency Contact Details - incl. cell phone #
Medical Conditions (indicate "none" or list all): *
Medications currently on (indicate "none" or list all): *
Allergies (indicate "none" or list all): *
Corrective Lenses (Y/N) *
Surgery / Operations / Procedures (list all in last 10 years & include dental): *
Last Tetanus Shot (year): *
Do you regularly get treatment for any conditions? (chiro, physio, etc.)
Have you EVER been diagnosed with a concussion? *
If you answered yes, please provide details of concussions incl. date(s) and weeks of sport missed.
Have you ever had your "bell rung"? *
Additional padding / braces / support you use to play lacrosse or any other sports: *
Please be as detailed and specific as possible to assist our training staff as and when needed
Neck
Provide details below:
Details
Please provide details of your injury, when it occurred / you received the diagnosis, what the prognosis / treatment plan was and how long before you could return to play
Shoulder
Please provide details of your injury, including LEFT or RIGHT or BOTH, when it occurred / you received the diagnosis, what the prognosis / treatment plan was and how long before you could return to play
Elbow:
Wrist / Hand
Hip / Pelvis:
Details:
Thigh / Hamstring:
Knee:
Foot / Ankle:
Do you regularly need / expect to see the trainer before taking the floor? (taping, stretching, etc.)
How can our trainer help you to be at your best?
Do you have issues in hot weather? *
Anything else our trainer needs to know? (Please list precautions, supplements, dietary, etc.)
Please verify that you are a human.
