2017 Maccabiah Games Physicians Medical Form This medical form must be completed and signed by the athlete’s physician. Question Title * 1. Participant (Athlete) Information - as it appears on your PASSPORT Last Name: First Name: Middle Name:(if not applicable enter NA) SPORT: Question Title * 2. Date of Birth Date Date Question Title * 3. Allergy: Question Title * 4. Tetanus Up to Date: Yes No Question Title * 5. MEDICAL/MSK History Question Title * 6. Surgery in the last 6 months: Yes No If yes, specify type: Question Title * 7. Did the athlete ever suffer a concussion: Yes No If yes, please expand: Question Title * 8. Family History of: Yes No Sudden Cardiac Demise Sudden Cardiac Demise Yes Sudden Cardiac Demise No Hypertrophic Cardiomyopathy Hypertrophic Cardiomyopathy Yes Hypertrophic Cardiomyopathy No Question Title * 9. Medication(s): *** If the medication an athlete is required to take to treat an illness or condition that happens to fall under the World Anti-Doping Prohibited List, a Therapeutic Use Exemption (TUE) may give that athlete the authorization to take the needed medicine.All athletes are required to check at:http://www.wada-ama.org/en/World-Anti-Doping-Program/Sports-and-Anti-Doping-Organizations/International-Standards/Prohibited-List/A TUE can be downloaded from the site and must be completed by your treating physician. Question Title * 10. Complete Physical Exam: BP: HR: Weight: Question Title * 11. Pertinent Findings: HEENT: Respiratory: CVS: GI: GU: MSK: CNS: Question Title * 12. All athletes 40 years and older require a pre-participation ECG.Please check one of the boxes below.Based on the ECG the athlete is: Able to participate Unable to participate Needs follow up before final decision is made Date of ECG: (mm/dd/yyyy):(ECG completed within 12 months from date of departure to games) Question Title * 13. Completed Examination: I have examined (name of patient) on (date of examination) Question Title * 14. It is in my opinion that this Maccabi Canada Athlete is medically cleared to engage in the Maccabiah Games July 2017 activities and athletic competitions without limitations or restrictions. Name of Treating Physician: Physician Address: Physician Phone Number: Question Title * 15. Date of completion Date Date Done