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    BFI Annual Medical Fitness Certificate-6

    Uploaded by

    Jalaj
    This document is an annual medical certificate for an athlete that requires signatures from the athlete and a medical doctor. It includes basic identifying information for the athlete and doctor. The doctor must indicate if the athlete is fit or unfit to box. It also includes a list of medical questions for the athlete and a medical examination checklist for the doctor to document any abnormalities.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    BFI Annual Medical Fitness Certificate-6

    Uploaded by

    Jalaj
    170 views3 pages
    This document is an annual medical certificate for an athlete that requires signatures from the athlete and a medical doctor. It includes basic identifying information for the athlete and doctor. The doctor must indicate if the athlete is fit or unfit to box. It also includes a list of medical questions for the athlete and a medical examination checklist for the doctor to document any abnormalities.

    Original Description:

    Fitness Certificate

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    This document is an annual medical certificate for an athlete that requires signatures from the athlete and a medical doctor. It includes basic identifying information for the athlete and doctor. The doctor must indicate if the athlete is fit or unfit to box. It also includes a list of medical questions for the athlete and a medical examination checklist for the doctor to document any abnormalities.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    170 views3 pages

    BFI Annual Medical Fitness Certificate-6

    Uploaded by

    Jalaj
    This document is an annual medical certificate for an athlete that requires signatures from the athlete and a medical doctor. It includes basic identifying information for the athlete and doctor. The doctor must indicate if the athlete is fit or unfit to box. It also includes a list of medical questions for the athlete and a medical examination checklist for the doctor to document any abnormalities.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Annual Medical Certificate

    Athlete
    NAME: _______________________________________________________________________________________

    DATE OF BIRTH: _______________________________________________________________________________________

    SIGNATURE: ________________________________________ DATE: __________________________________

    Medical Doctor
    NAME: _______________________________________________________________________________________

    TITLE/POSITION: ________________________________________________________________________________

    ADDRESS: _______________________________________________________________________________________

    SIGNATURE: _______________________________________ DATE: ____________________________________

    COMMENTS: _______________________________________________________________________________________

    _______________________________________________________________________________________

    Fit to Box 
    Not Fit to Box 

    BFI Annual Medical Certificate page 1/3


    Annual Medical Certificate

    QUESTIONS FOR ATHLETE: IF YES, EXPLAIN

    1. Is a doctor currently treating you for anything?


    ____________________________________________________________________________________________________

    2. Have you ever been unconscious or had a concussion?


    ____________________________________________________________________________________________________

    3. Have you been hit hard in the head in the last 6 weeks?
    ____________________________________________________________________________________________________

    4. Have you had any headache in the last 2 weeks?


    ____________________________________________________________________________________________________

    5. Do you have any problem with bleeding?


    ____________________________________________________________________________________________________

    6. Do you have a history of hepatitis B or hepatitis C or HIV infection?


    ____________________________________________________________________________________________________

    7. Does any disease run in your family? Sudden unexpected deaths?


    ____________________________________________________________________________________________________

    8. Have you had any surgery?


    ____________________________________________________________________________________________________

    9. Have you ever had to stay in a hospital?


    ____________________________________________________________________________________________________

    10. Do you have any medical condition?


    ____________________________________________________________________________________________________

    BFI Annual Medical Certificate page 2/3


    Annual Medical Certificate

    MEDICAL CERTIFICATE ABNORMALITIES


    Medical Examination
    If Athlete had a
    following rest period after
    Concussion in the past Normal Abnormal
    Concussion was normal.
    year, please certify that:
    Athlete Fit To Box
    List abnormalities not
    General Medical Exam covered in specific system
    exams below:
    Mental Status/
    Psychological Brief survey Normal Abnormal

    Cranial nerves, eyes, pupil


    size and reactivity. Fundi. Normal Abnormal
    Vision by chart (record)
    Head Mouth , teeth, throat Normal Abnormal
    Ears Normal Abnormal
    Temporomandibular joint Normal Abnormal
    Neck Cervical spine, lymph nodes Normal Abnormal
    Breath sounds, rib
    Chest Normal Abnormal
    tenderness on compression
    Pulse/blood pressure
    Normal Abnormal
    (record)
    Cardio Vascular System Heart examination: sounds,
    murmurs, heaves, size, Normal Abnormal
    rhythm
    Upper limb: shoulder, wrist,
    Normal Abnormal
    hand, fingers
    Orthopedic System
    Lower limb: foot, ankle,
    Normal Abnormal
    knee, hip
    Reflexes Normal Abnormal
    Verbal responses Normal Abnormal
    Neurological System
    Motor responses
    Normal Abnormal
    and balance
    (record) Yes No
    Allergies
    Type of reaction (record)
    Medications used Name and dosage (record) Yes No

    Any TUE Submitted ? NO YES(if YES, please explain)


    ____________________________________________________________________________________________________

    BFI Medical Certificate page 3/3

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