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Ak Promotions
Events
Register for an Event
IKF Rules & Regulations
IKF PKB Rules
IKF Rankings
Sanction an Event with Us
Participating Gyms
Promoters & Officials
About
Contact Us – Be a Guest on Johnny Davis Live!!!
Pre-Fight Exam Form
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Date of Birth
*
Gender
*
Male
Female
FIGHTER: Please fill out ALL of the Following Questions before your Pre-Fight Fighter Physical- Check Below
Do you have Medical insurance?
Yes
No
Any Chronic Medical Conditions? ( Diabetes, Asthma, Heart Condition etc.)
Yes
No
If Chronic Medical Conditions ...Please Explain Below
Ever had any surgeries?
*
Yes
No
If any surgeries ...please explain below or put N/A
Have you ever been hospitalized?
Yes
No
If you have been hospitalized - Please Explain Here
Have you ever had a fracture?
Yes
No
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?
Yes
No
If any strains or sprains - please explain on what part of the body- Month,Date and Year
Any Vision Problems
Yes
No
Do you wear contact lenses?
Yes
No
Have you ever passed out while exercising?
No
Yes
If you have ever passed out while excercising- Please explain here
Have you ever had chest pains while exercising?
Yes
No
If you have ever had chest pains while exercising explain below
Have your ever felt dizzy while exercising?
Yes
No
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?
Yes
No
Any Congenital such as single Kidney, undescended testicle, Cardiac defect?
Yes
No
Do you have any hernias, groin or abdominal pain?
Yes
No
Ever had head injury or concussion or been knocked unconscious?
Yes
No
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?
Yes
No
Have you ever had a heat stroke
*
No
Yes
Do you have any drug allergies?
*
Yes
No
WOMEN: Are You Pregnant? Note: A pregnancy test is required
No
Yes
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.
Doctor To Fill out 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
Δ