ISA Medical Questionnaire

Ice Skating Australia Incorporated

Affiliated to the International Skating Union
This form will be forwarded directly to ISA Chief Medical Officer, Dr Asher Livingston.
Medical Questionnaire

CONFIDENTIAL
Sections to be Completed:

Section 1 - Contact Information

Section 2 - Medical Details

Section 3 - Athlete Declaration

Please ensure all sections are completed before submitting.
Section 1 - Contact Information
Athlete Contact
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
E-mail *
Phone Number *
Next of Kin
Full Name *

First Name Last Name
Relationship to Athlete *
E-mail *
Phone Number *

Section 3 - Athlete Declaration
To the best of my knowlegde, all the information contained on this sheet is correct. I understand I am ultimately responsible for my own health and well-being and professional medical advice should be sought for any sporting activity injury.
I Agree *

Yes
Signature of Athlete *
Date *

Month Day Year
Signature of Parent or Guardian (If athlete is under 18 years of age)
Date *

Month Day Year
Enter the message as it's shown *
Should be Empty:

Ice Skating Australia Incorporated