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Member medical form.xls

For Wheelchair Sports Victoria programs involving participants aged 20 years of age or younger.
PERSONAL INFORMATION
DISABILITY INFORMATION
MEDICATIONS
Please list all medication taken regularly or currently being taken: Medication
Times Taken
Would you prefer that the medication is kept and administered by the appointed Program Nurse…? NOTE: If participant needs a reminder to take medication, it is recommended that medication is provided to the appointed Program Nurse for
administering, to ensure no missed doses.
Please list any known drug
allergies
& the reaction they
cause.
(eg. Bactrim causes a rash)
Please provide any specific instructions regarding administration of medication.
(eg. Crushed with honey) INDIVIDUAL DIET
Please list any known food
allergies
.
(including possible reactions)
Please list any foods or fluids
that are NOT allowed.
Please list any foods or fluids
which SHOULD be encouraged.
Please list any other special assistance required with meals.
INDIVIDUAL MOBILITY
Dependant upon use of a wheelchair at all times…? Usually walks but uses a wheelchair intermittently…? If YES, please specify when use of a wheelchair is necessary.
Uses any of the following mobility aids…? If using AFO's, please indicate when they are worn.
(eg. At all times, during day) Please provide any further relevant information regarding individual mobility.
INDIVIDUAL TRANSFERS
Wheelchair to Seat (eg. Bus)
Please provide any further relevant information or details.
Wheelchair to Toilet
Please provide any further relevant information or details.
Wheelchair to Shower
Type of shower chair used at home.
(eg. Commode, plastic, arms) Please provide any further relevant information or details.
Is a hoist used for transfers at home…? PERSONAL CARE
Does the participant require assistance with bathing, showering, If YES, please provide details of any assistance required.
When does the participant prefer to shower…? Toileting
Please be specific when completing details about management regarding toileting requirements. Our aim is to assist in the maintenance of a participants normal routine wherever possible considering available facilities and equipment. As such, it is a requirement that all necessary appliances and supplies (eg. pads, catheters, drainage bags .etc) are provided to last the duration of the program. This will assist in minimising any potential embarrassment or inconvenience to the participant if borrowing of supplies is necessary.
Bowel Management
Self-care with NO assistance required
Self-care with SOME assistance required
FULL assistance required
If SOME or FULL assistance required, please specify assistance required.
Is there any other form of assistance required…? If YES, please provide details of any assistance required.
Urinary Management
Self-care with NO assistance required
Self-care with SOME assistance required
FULL assistance required
If SOME or FULL assistance required, please specify assistance required.
Catheter Type
Catheter Size
Catheter Frequency or Times
Every 4 hours - 0800 / 1200 / 1600 / 2000 Does the participant require assistance with catheters…? If YES, please provide details of any assistance required.
If no assistance is required with catheters, does the participant require reminding to self catheterise…? Does the participant wear incontinence products…? Please list any other toileting assistance required.
GENERAL INFORMATION
Does the participant have any pressure areas or current injury If YES, please provide details of any assistance required.
Please provide any additional information that you feel is relevant for the medical care (if required) of the participant.
AUTHORISATION
I acknowledge that the Medical Information that I have provided is true and accurate.
I also acknowledge, that in the event of the participant listed on this Medical Information Form requiring medical attention, I understand that the appointed Coordinator / Manager / Medical Staff of the Program will make reasonable attempts to communicate with me concerning the required action.
I further acknowledge, that if it is not possible to make contact with me, I authorise the appointed Coordinator / Manager / Medical Staff to administer or seek whatever medical treatment is determined to be reasonably necessary.
Confidentiality & Privacy:
Wheelchair Sports Victoria agrees to keep the above information confidential and continue to respect the privacy of each participant.
Following participation in the identified program or event, this information will be maintained on file for future participation - if you wish for the
information not to be kept on file, please confirm in writing to Wheelchair Sports Victoria.
Please return complete forms (5 pages) by post, email or facsimile using the details below:

Source: http://www.disabilityconnections.org.au/sites/www.disabilityconnections.org.au/files//news/2010/11/355232-upload-00001.pdf

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