Special Olympics Medical Form

Special Olympics Medical Form – Athlete Health History, Physical Exam, and Release

Athlete Medical Form – HEALTH HISTORY

(pages 1 & 2 to be completed by the athlete or parent/guardian/caregiver)

Region/Area:

Delegation/Team:

Does the athlete have (check any that apply):

Autism Down syndrome Fragile X Syndrome
Cerebral Palsy Fetal Alcohol Syndrome Other syndrome, please specify:

Has a doctor ever limited the athlete’s participation in sports? No Yes

If yes, please describe:

Is the athlete allergic to any of the following (please list):

Latex

No Known Allergies

Medications:

Insect Bites or Stings:

Food:

List any special dietary needs:

Does the athlete use (check any that apply):

Brace Colostomy Communication Device
C-PAP Machine Crutches or Walker Dentures
Glasses or Contacts G-Tube or J-Tube Hearing Aid
Implanted Device Inhaler Pacemaker
Removable Prosthetics Splint Wheel Chair

List all past surgeries:

Has the athlete had a Tetanus vaccine in the past 7 years? No Yes

Does the athlete currently have any chronic or acute infection? No Yes

If yes, please describe:

FAMILY HISTORY

Has any relative died of a heart problem before age 50? No Yes

Has any family member or relative died while exercising? No Yes

Has the athlete ever had an abnormal Electrocardiogram (EKG) or Echocardiogram (Echo)? No Yes

Yes, had abnormal EKG Yes, had abnormal Echo

List all medical conditions that run in the athlete’s family:

HAS THE ATHLETE EVER BEEN DIAGNOSED WITH OR EXPERIENCED ANY OF THE FOLLOWING CONDITIONS

Difficulty controlling bowels or bladder No Yes

Describe any past broken bones or dislocated joints:

If yes, is this new or worse in the past 3 years? No Yes

Numbness or tingling in legs, arms, hands or feet No Yes

If yes, is this new or worse in the past 3 years? No Yes

Weakness in legs, arms, hands or feet No Yes

If yes, is this new or worse in the past 3 years? No Yes

Burner, stinger, pinched nerve or pain in the neck, back, shoulders, arms, hands, buttocks, legs or feet No Yes

If yes, is this new or worse in the past 3 years? No Yes

Head Tilt No Yes

If yes, is this new or worse in the past 3 years? No Yes

Spasticity No Yes

If yes, is this new or worse in the past 3 years? No Yes

Paralysis No Yes

If yes, is this new or worse in the past 3 years? No Yes

Epilepsy or any type of seizure disorder No Yes

If yes, list seizure type:

If yes, had seizure during the past year? No Yes

Self-injurious behavior during the past year No Yes

Aggressive behavior during the past year No Yes

Depression (diagnosed) No Yes

Anxiety (diagnosed) No Yes

Describe any additional mental health concerns:

List any other ongoing or past medical conditions:

PLEASE LIST ANY MEDICATION, VITAMINS OR DIETARY SUPPLEMENTS BELOW

(includes inhalers, birth control or hormone therapy)

Is the athlete able to administer his or her own medications? No Yes

If female athlete, list date of last menstrual period:

Athlete Medical Form – PHYSICAL EXAM

(to be completed by a Medical Professional only)

MEDICAL PHYSICAL INFORMATION (TO BE COMPLETED BY EXAMINER ONLY)

Blood Pressure Right: Left:

Vision Right: Left:

Right Hearing (Finger Rub):

Left Hearing (Finger Rub):

Right Ear Canal:

Left Ear Canal:

Oral Hygiene:

Thyroid Enlargement: No Yes

Lymph Node Enlargement: No Yes

Heart Rhythm:

Lungs:

Radial Pulse Symmetry:

ATLANTO-AXIAL INSTABILITY (AAI)

Athlete shows NO EVIDENCE of neurological symptoms or physical findings associated with spinal cord compression or atlantoaxial instability.

Athlete has neurological symptoms or physical findings that could be associated with spinal cord compression or atlantoaxial instability and must receive an additional neurological evaluation to rule out additional risk of spinal cord injury prior to clearance for sports participation.

RECOMMENDATIONS (TO BE COMPLETED BY EXAMINER ONLY)

This athlete is ABLE to participate in Special Olympics sports without restrictions/limitations

This athlete is ABLE to participate in Special Olympics sports WITH restrictions/limitations

This athlete MAY NOT participate in Special Olympics sports at this time and MUST be further evaluated by a physician for the following concerns:

Concerning Cardiac Exam Acute Infection O2 Saturation Less than 90% on Room Air
Concerning Neurological Exam Stage II Hypertension or Greater Hepatomegaly or Splenomegaly
Other, please describe:

Additional Licensed Examiner’s Notes and Recommended Follow-up:

Other/Exam Notes:

Athlete Medical Form – MEDICAL REFERRAL FORM

(to be completed by a Medical Professional only if referral is needed)

This page only needs to be completed and signed if the physician on page three does not clear the athlete and indicates follow-up is required.

Examiner’s Name:

Specialty:

I have examined this athlete for the following medical concern(s):

In my professional opinion, this athlete MAY participate in Special Olympics sports:

Yes, without restrictions Yes, but with restrictions No

Additional Examiner Notes/Restrictions:

Examiner E-mail:

Examiner Phone:

License:

This section to be completed by Special Olympics staff only, if applicable.

This medical exam was completed at a MedFest event? Yes No

The athlete is a Unified Partner or a Young Athlete Participant? Unified Partner Young Athlete

ATHLETE RELEASE FORM

I want to take part in Special Olympics and agree to the following:

1. Able to Participate. I am able to take part in Special Olympics. I know there is a risk of injury.

2. Photo Release. Special Olympics organizations may use my picture, video, name, voice, and words to promote Special Olympics.

3. Overnight Stay. For some events, I may stay in a hotel or someone’s home. If I have questions, I will ask.

4. Emergency Care. If I am unable, or my guardian is unavailable, to make medical decisions in an emergency, I authorize Special Olympics to seek medical care on my behalf, unless I check one of these boxes:

I have a religious or other objection to receiving medical treatment.

I do not consent to blood transfusions.

5. Health Programs. If I take part in a health program, I consent to health activities, exams, and treatment.

6. Personal Information. I understand my information may be used and shared by Special Olympics as described in the release.

ATHLETE NAME: