S-3.1, r. 11 - Regulation respecting combat sports

Schedule Disposition versions

2012-09-01

SCHEDULE 1-B

MEDICAL EXAMINATION FOLLOWING A BOUT

MEDICAL EXAMINATION FOLLOWING A BOUT
Regulation respecting combat sports (s. 159, 1st par., subpar. 4)

This form must be completed at the conclusion of any bout in which the contestant has participated. The medical condition of the contestant and any injury sustained during the bout must be noted herein. This report must also be completed where a contestant has sustained an injury while training or in any other circumstances.
1.1 Name		1.2 Pseudonym (if any)		
1.3 Address - Street	Apt.	City or town	Province - State - Country		
1.4 Postal code	1.5 Date of birth	1.6 Weight	Date of the injury		

	Y	M	D	Y	M	D
	
General condition of contestant: 	
	
Specify any injury reported by contestant: 	
	
	
Treatment prescribed: 	
	
	
Tests or examinations administered (please indicate and/or attach results).
A copy of EEG and ECG reports and ophtalmological reports must be forwarded to the board.
	
	
	
Recommendations: 		
Physician’s signature: 	 Date: 	
			
OFFICIAL USE ONLY
	
Name of 	Nature of
contestant: 		the injury: 	
Date of	Length of	Date
suspension:	suspension: 		suspension lifted:
	Y	M	D		Y	M	D
	

O.C. 662-95, Sch. 1-B.