FITNESS PADDLERS AUSTRALIA (FPA) - TIME TRIALS & EVENTS MEDICAL INFORMATION FORM
NAME: Surname: ………………………………….…………….… Given / Preferred Name:….…………………………………….
HOME ADDRESS: ……………………………………….……………………………………………………………………………….
Suburb/Town: ……………………………………………………………….…. State: ….……. Postcode: ……………….
CONTACT: Telephone: ……………….…….……. Home or Business (please circle) Mobile: ….…….……………………………
PERSONAL: Date of Birth: …………/…………/…………. Age at Race ……………. Gender: Male • Female •
Medicare Number: ……………………………….………
Private Health Insurance: …………………………………. Private Health Ins Number: ……………………….……………….
Ambulance Ins Number: ………….…….………………….
EMERGENCY USE: Details of a person who can be contacted during the Fitness Paddlers Australia Time Trial Events.
NAME: …………………………………………………. Relationship: ………………………………………………………
ADDRESS: …………………………………………………… Suburb: ………………………………………. Postcode: ……………
Contact Phone: ……………………………………………… Mobile: ………………………………………….
Name and address of family doctor or clinic: …………………………………………………………………………….…… Phone: ……………….……….
Name and address of any relevant specialist: ……………………………………….…………………………………….… Phone:….…………….
Each paddler shall disclose any chronic or recurrent ailment, allergy or physical incapacity suffered for the purpose of medical support staff preparedness.
A. Does the paddler suffer from any physical or other disabilities?
If YES, please specify: …………………………………………….……………………………………………………………………….
Asthma? ……………. Severe / Mild YES / NO
Diabetes? ……….Type 1 / Type 2 YES / NO Seizures or Convulsion? Severe / Mild YES / NO
Dizzy spells or Blackouts? ……………. YES / NO Heart Disease? ………………. YES / NO High Blood Pressure? …………………. YES / NO
Explanation / Medication: ………………………………………………………………………………………………………………….
C. Does the paddler have any known allergies? i.e. Penicillin, bee stings, insects, hay fever, food (including nuts), drug, other environment related allergy. YES / NO
If YES, please specify: ………………………….…………………….……………………………………………………………………
D. Does the paddler carry with them any medications while paddling? i.e. injection/tablet/capsule, Insulin, Ventolin, other Drugs.
Name of Drug: ………………………………………………….……………. Dosage: …………………………………….
Reason or Cause: ……………………………………………….……………… How Often Administered: …………………………
Administered by Whom: …………………………………….…………………
E. Is there any further information you may consider necessary, about which we have not asked above and of which we
should be aware? (include hospital admissions and operations)
If YES, please specify: ………………….…………………………………………………………………………………………………
F. Details of last Anti-Tetanus Injection? .
Year of Last Booster injection: ……………………
I hereby Authorise FITNESS PADDLERS AUSTRALIA (FPA) Time Trials & Events, in circumstances where it is not possible or it is impracticable to communicate
with me, to seek for me or the person named on this form, such Surgical, Medical or Dental treatment as a qualified Surgeon, Medical or Dental Practitioner may
consider to be necessary (including the transfusion of blood) and I hereby Consent to such treatment.
Signed: ………….……………………………………. (to be signed by Parent or Guardian for paddlers under 18 years of age)
Date: …………………………….
Please complete a separate medical declaration form for each paddler entered (photocopy extra forms as required).
Send it to us with your entry form. No paddler is entitled to start in the named events without having first submitted this form completed. This important information
that shall be treated as CONFIDENTIAL and will be destroyed if you choose not to stay registered with Fitness Paddlers Australia.
Paddlers Name: ………………………………………………………………………………………………….
PLEASE NOTE All Paddlers MUST complete a Medical History form before your entry will be accepted.
TRAVEL CLINIC SCHEDULE (Please see read the patient information sheet before completing the schedule You may need travel vaccinations depending on the country you intend to visit. In order to provide this advice, please complete this form and return it to Reception as soon as possible prior to travel. You should allow at least 6 weeks prior to travel . You should contact us 14 days from the