ES Adaptive Doctor Form

Name of ES adaptive client *

Medical Assessment Form - For Your Doctor to Complete

For a hardcopy of this form please email adaptive@europeansnowsport.com.

Please advise us on the suitability of the applicant to participate in adaptive skiing.
To your knowledge, does the applicant have any of the following that would render them unsafe to participate:

PRECAUTION (Yes = please state details, No = X)

Fatigue

Cardiac arrhythmias

AVM/cerebral aneurysm

Significant carotid stenosis/dissection

Recent PE/DVT

Stroke or TIA in the last 4/52

Painful joints

Safety awareness/sensory/visual awareness

Behavioural problems

Diabetes

Use of beta blockers

Use of cerebral artery vasodilators

Central nervous drugs

Anti-coagulant therapy

End stage renal failure

Respiratory problem

Epilepsy

No bone flap

Vertigo/nausea

Infection/immuno-suppressed

Open wounds/pyrexia/pressure sores

CONTRAINDICATIONS (Yes = give details, No = X)

Unstable chest pain

Peripheral arterial occlusive disease

Febrile illness

IN THE CIRCUMSTANCE OF DOWNS SYNDROME (Yes = give details, No = X)

Presence of Atlanto-axial instability

Are there any other factors that you think may influence the applicant's suitability to participate in adaptive skiing?

MEDICATION

Please state all medications currently required (name of drug, dosage, time taken)

Name of doctor/Signature of doctor *

Date *