Safety Guidelines for Secondary Interschool Athletics in Alberta

Appendix M - Sample Medical History Card
This is an example of a portable method of recording medical history.
Name:______________________________________________________________________________
Date of Birth (M/D/Y): ______/______/______
Person to be contacted in case of emergency:
Phone (day):_______________________________
Phone (night):_______________________________
Alternative Contact:
Phone (day):_______________________________
Phone (night):_______________________________
Family Doctor: ______________________________
Phone: _____________________________________
Alberta Health Care # (OPTIONAL):_____________________________________________
Relevant Medical History: ____________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Medications: _______________________________________________________________________
__________________________________________________________________________________
Allergies: __________________________________________________________________________
__________________________________________________________________________________
Previous Injuries: ___________________________________________________________________
__________________________________________________________________________________
Does the athlete carry and know how to administer his or her own medications?
Yes
No
Other conditions; e.g., braces, contact lenses:____________________________________________
NOTE: Medical information is confidential. Keep this card with the team at all times. These cards
should not be available to other than authorized individuals.
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Safety Guidelines for Secondary Interschool Athletics in Alberta - February 2012