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

Schedule Disposition versions

2012-09-01

SCHEDULE 1-A

MEDICAL EXAMINATION

MEDICAL EXAMINATION
Regulation respecting combat sports (s. 159)
*	Boxing	*	Medical examination required to obtain a contestant’s licence (Complete sections I, II, III, IV and V).
*	Kickboxing	*	Medical examination required when a Québec contestant wishes to participate in a combat sports event (Complete sections I, III and V).
		*	Medical examination immediately prior to a bout (Complete sections I, III and V).
SECTION I - IDENTIFICATION OF APPLICANT						
1.1 Name	First 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						
___________ kg (lb)						
							
SECTION II - MEDICAL AND FAMILY HISTORY						
Indicate any contraindications to fighting: 							
						
SECTION III - MEDICAL EXAMINATION						
3.1	Hearing	Is there perforation of the tympanum?	Yes	*	No	*
		Is there hypacusis?	Yes	*	No	*
		Is there chronic otitis?	Yes	*	No	*
3.2	Vision	Is there	s Isochoria?	Yes	*	No	*
			s Is the light reflex normal?	Left: Yes *	No *	Right:	Yes	*	No	*
			s Is the fundoscopic examination normal?	Left: Yes *	No *	Right:	Yes	*	No	*
		Vision	Left: 	/20	Right:		/20			
3.3	Mouth	Is there any disease of the mouth or throat?	Yes	*	No	*
3.4	Neck (glands)	Is there any enlargement of the thyroid or lymph glands?	Yes	*	No	*
3.5	Respiratory system	Is there any evidence of 	- acute respiratory disease?
	- chronic respiratory disease?	Yes
Yes	*
*	No
No	*
*
3.6	Blood pressure		Systolic	Diastolic	At disappearance of sound
1st reading						
2nd reading										
3.7	Heart	Pulse measured by cardiac auscultation for 1 minute					
		Is there any irregularity in the heartbeat?	Yes	*	No	*
		Is there any evidence of disease of the heart or blood vessels?	Yes	*	No	*
3.8	Abdomen	Does examination reveal any abnormality? (hepatomegaly, splenomegaly)
If so, specify: 		Yes	*	No	*
3.9	Hernia	Is there any hernia?	Yes	*	No	*
3.10	Nervous system	Is there any evidence of impairment of the nervous system?	Yes	*	No	*
3.11	Hands	Is there any evidence of swelling or injury?	Yes	*	No	*
3.12	Alcohol	Is there any evidence of the use of alcoholic beverages?	Yes	*	No	*
	Drugs	Is there any evidence of the use of stimulants?	Yes	*	No	*
	Tobacco	Is tobacco used?	Yes	*	No	*
3.13	General condition	Is there any evidence of a pathological condition not specifically described above and for which an additional examination would be required?	Yes	*	No	*
3.14	Thorax	Is there a fracture of the ribs?	Yes	*	No	*
3.15	Facial bones
Nose
Maxilla	Has there been a recent fracture or sprain?	Yes	*	No	*
3.16	Feet
(for kickboxers)	Has there been a recent fracture or sprain?	Yes	*	No	*
3.17	Breasts
(for female contestants)	Does the examination reveal any abnormality?
Is a breast prosthesis used?(1)	Yes
Yes	*
*	No
No	*
*
3.18	Eyes	Examination by an ophtalmologist if the contestant is 40 years of age or older	Normal			*
			Abnormal			*
						
SECTION IV - LABORATORY TESTS						
4.1	EEG	Normal *	Abnormal *
Attach a copy of the reports.				
4.2	Exercise ECG
(if the contestant is 40 years of age or older or if he has had a physical examination which suggests cardiac problems).	Normal *	Abnormal *
Attach a copy of the reports.				
4.3	Pregnancy	Pregnancy blood test 7 days before the event(1)	Positive
Negative			*
*
4.4	Hemogram	* Hepatitis B	* Hepatitis C	* HIV	* Negative				
						
SECTION V - OTHER (If applicable)						
5.1	Remarks: 	
	
						

(1) A female contestant who uses a breast prosthesis or who is pregnant shall not be declared fit to fight.
I hereby certify that I have examined the above-named applicant and that, as a result of the examination, I consider the applicant to be:
Fit * 		Unfit *	to fight.
Signature: 		Date: 	
	(examining physician)	year 	month 	day

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