Confidential Emergency Medical Information Form

This Document is meant to provide the correct information to Medical Team providing medical
support. The Medical Information will be conveyed only for treatment purposes and is for assisting
the Medical Team to have the right information in case of Emergency. THE INFORMATION OF THIS
FORM WILL REMAIN CONFIDENTIAL.

Name:
Address:
Age:
Date of Birth:
Gender:
Blood Group:

1. Do you have any Medical Condition(s) which your healthcare provider should be aware of?
 Yes  No
If yes, Give details:
………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………..
2. Do you have any known allergies?
 Yes  No
If yes, Give details:
………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………..
3. Are you currently on any medication?
 Yes  No
If yes, Give details:
………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………….
4. Name and contact number of your own doctor:
………………………………………………………………………………………………………………………………………………
5. Person to be contacted in Emergency:
Name: ……………………………………………………………………………………………………………………………………
Relationship: …………………………………………. Contact No. ……………………………………………………......

I acknowledge that the information provided in this form will be meant only for Medical
Treatment purposes and in the event of Medical Emergency.

Signed:
Dated:
 Department of SPORTS

For Use of Swimming Pool Facility(Version1.4)

Candidate Name: ……………………………………………………………………………

Paste you photo here
Age:
Gender:
Height(cm):
Weight(Kg):

Declaration by Candidate of Following Details:

1. Any history of Epilepsy(fits), Dizziness, Asthma, TB, Allergy, Venereal Disease: Yes/No
2. History of Water phobia: Yes/ No
3. History of Diabetes, Heart Problems: Yes/ No
4. Have you ever swum in swimming pool/river/lake etc.? Yes/No

Undertaking by Candidate:

I, Mr/Ms …………………………………………………………………… have submitted correct details above.

Candidate Signature: …………………………….

Candidate is inspected for Infections/ Communicable diseases:

Heart Rate (per minute):

Blood Pressure (S/D mm of Hg):
1. Skin Infection
2. Eye
3. Ear
4. Throat
I hereby certify that I have examined Mr/Ms ………………………………on date …………… time……………. and
on inspection he is found to be free of communicable diseases.

Medical Staff Signature:

Name of Staff:
Date: