This medical form must be completed and signed by the athlete’s physician.

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* 1. Participant (Athlete) Information - as it appears on your PASSPORT

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* 2. Date of Birth

Date

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* 3. Allergy:

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* 4. Tetanus Up to Date:

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* 5. MEDICAL/MSK History

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* 6. Surgery in the last 6 months:

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* 7. Did the athlete ever suffer a concussion:

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* 8. Family History of:

  Yes No
Sudden Cardiac Demise
Hypertrophic Cardiomyopathy

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* 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.

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* 10. Complete Physical Exam:

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* 11. Pertinent Findings:

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* 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:

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* 13. Completed Examination:

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* 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.

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* 15. Date of completion

Date

T