Pre-Fight Exam Form - Ak Promotions

Pre- Fight Exam Form for ECC Classic

This form is to be filled out by all competitors competing in the East Coast Classic Full Contact tournaments

Date*
MM slash DD slash YYYY
Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Gender*
FIGHTER: Please fill out ALL of the Following Questions before your Pre-Fight Fighter Physical- Check Below
Do you have Medical insurance?
Any Chronic Medical Conditions? ( Diabetes, Asthma, Heart Condition etc.)
If Chronic Medical Conditions ...Please Explain Below
Ever had any surgeries?*
If any surgeries ...please explain below or put N/A
Have you ever been hospitalized?
If you have been hospitalized - Please Explain Here
Have you ever had a fracture?
If you have ever had a fracture or dislocation...please explain where and when...give Month- Date and Year*
Have you ever had a strain or sprain that required equipment and braces?
If any strains or sprains - please explain on what part of the body- Month,Date and Year
Any Vision Problems
Do you wear contact lenses?
Have you ever passed out while exercising?
If you have ever passed out while excercising- Please explain here
Have you ever had chest pains while exercising?
If you have ever had chest pains while exercising explain below
Have your ever felt dizzy while exercising?
If you have ever felt dizzy while exercising? - Explain here - Give Est. Month - - Date and Year
If you have had any heart related issues like Mumurs, AFFIB, Etc - Please note below or put N/A
Any family members die suddenly before the age of 50?
Any Congenital such as single Kidney, undescended testicle, Cardiac defect?
Do you have any hernias, groin or abdominal pain?
Ever had head injury or concussion or been knocked unconscious?
If you have ever been knocked unconscious or had a concussion ... please note Month, Date and Year below..also please inform the physician of this verbally
Have you had a pinched nerve, numbness or tingling in the arms, hand or feet in the past year?
Have you ever had a heat stroke*
Do you have any drug allergies?*
WOMEN: Are You Pregnant? Note: A pregnancy test is required
If you refuse medical care and, or transport suggested by our event Physician, you are accepting all liability and will not be covered under our secondary event insurance coverage. Moreover, you release all other parties involved with this event i.e, promoter, venue, officials and others, from all Liability. Sign name below that you agree to the aforementioned statement regarding refusal of medical care*
Parent or Guardian Signature for a minor regarding refusal of Medical Services*
Date
MM slash DD slash YYYY
STOP: Doctor to Fill Out and Signoff on all information below.
The Event Medical Doctor is to fill out and sign off on all information below. Any fraudulent information on this form or any attempt to misled officials will have you removed suspended etc. from this event.
Time of Physical:*
Fighter's Pulse*
Fighter's Blood Pressure*
Fighter's Hands*
Fighter's Eyes*
Fighter's Heart*
Fighter's Lungs*
Fighter's Hernia / Abdomen*
Official Weight of Fighter*
Doctor's Electronic Signature Below*
Doctor's Name Printed*
Date
MM slash DD slash YYYY