EKO Health information
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- Meagan Barber
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1 EKO Health information The following form comprises of two sections. Section 1 is a declaration of general health information and has to be filled out by the fighter himself. Section 2 is a guideline for a 'fit for match' medical evaluation which has to be filled out by the fighter's doctor. Section 1. General health information Name of tournament: Year: Surname: Given name: Address: City: Country: Postcode: Tel: (with international code) Age: years Sex: Male Female Weight:, Kg Do you use visual correction? No Yes glasses Yes contact lenses Du you suffer from any diseases? Diabetes? No Yes Allergy? No Yes Asthma? No Yes Epilepsy? No Yes Cardio-vascular disorders No Yes Other diseases? Write here : EKO health information Page 1
2 Do you take any medicine No Yes if yes fill this form: (remember to check if your medicine is on the WADA prohibited list. If it is, you should have a TUE (Therapeutic Use Exemption) from your country antidoping organization. This form shall be send to the tournament organizer and the EKO Doping Committee, within a month before the tournament It is each fighters personal duty to ensure that no Prohibited Substance, enters his or her body. Fighters are responsible for any Prohibited Substance or its Metabolites or Markers found to be present in a doping test Medicine, Generic name Dose Route Frequency If you use medicine, it is your responsibility that your coach is aware of this, and have any acute medication nearby, and that your coach is familiar with the use of your medicine. Have you been unconscious before? No Yes date for the last time: Do you suffer from any present or previous injuries? No Yes Which Do you feel in good health? Yes No Other relevant health information: EKO health information Page 2
3 If you are female: Pregnant/signs of pregnancy? No Yes = PARTICIPATION NOT ALLOWED Incorrect or missing statements may cause rejection of your participation in the tournament. Your information shall not be registered and is only used for the current tournament Supportive and protective bandage is not allowed in the first fight. All bandages must be authorized before use by one of the official doctors. Fist you must show your damage to the tournament doctor. Then you and your coach do the bandages. Then the tournament doctor approves your bandage with a stamp or signature. Participation is at the fighters own risk. I, as a participant in the tournament, hereby declare as follows: 1. I confirm that I shall comply with and be bound by all of the provisions of the EKO Anti- Doping Rules, including but not limited to, all amendments to the Anti-Doping Rules and all International Standards as issued by the World Anti-Doping Agency and permanently published on its website. 2. I acknowledge that EKO have jurisdiction to impose sanctions as provided in the EKO Anti- Doping Rules. 3. I have read and understand the present declaration. I accept the statements above and declare my information is correct. Date Print Name (Last Name, First Name) Date of Birth (Day/Month/Year) Signature (or, if minor, signature of legal guardian) EKO health information Page 3
4 Section 2. Fit for match medical evaluation. This form is a guideline for the fit for match medical evaluation. If the performing physician feels to add additional tests he is free to do so. A copy of the complete form must be kept by the physician and one by the fighter. A copy of the signature page must be submitted to the tournament doctor. Date Length Weight Fatpercentage General impression (Injury to wrist, hands, eyebrow, face, ears and nose; posture) Nose: clearance Septum rhinosc. anter. Oren: outer hearcanal Tympanic membrane Thorax: inspection Movement Pressure pain? Cor: auscultation Pulse Bloodpressure Pulmones: borders percussion Auscultation Abdomen: inspection Auscultation Percussion Palpation Hepar Lien Vertebrae Eyes: pupilreaction, size left-right Neurological: Mouth: tonsills phar. Arch teeth Urine: alb. ery. i Gnostic sensibility Bicepsreflex Tricepsreflex Knee reflex Achilles ten reflex Babinsky reflex Romberg top-nose test Knee-heel test 1st check up 2nd check up 3rd check up 4th check up EKO health information Page 4
5 Other remarks Name, date and stamp physician I Date and autograph fighter II III IV Version 2011 EKO health information Page 5
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