21st ASEAN University Games 2024

Combat Sports

ASEAN UNIVERSITY SPORTS COUNCIL

ATHLETE’S MEDICAL DECLARATION FORM
NUSF
Full Name
Date of Birth NRIC / Passport No
Sports Gender Male / Female

MEDICAL HISTORY
* Does the athlete have any of these? Tick (√) where appropriate:
Illness Yes No
1. Asthma
2. Heart Illness
3. High Blood Pressure
4. Diabetes
5. Epilepsy/Seizure
6. Handicapped
7. *History of surgery
*If yes, state the name of surgery and when: ……………………………………………………………………………..
PHYSICAL EXAMINATION

Systolic mm Hg
1. Blood Pressure (BP)
Diastolic mm Hg
2. Pulse (PR) bpm
3. Heart
4. Lung
5. Abdomen
6. Pupils (Equal/Reactive)
7. Neurology
8. Musculoskeletal
9. Others
Notes: ………………………………………………………………………………………….
I hereby confirm that the athlete:
Medically FIT to compete.
Medically NOT FIT to compete.

Date: …………………… ………………………………..

Doctor’s Name:
Address of Health Centre:
Doctors Stamp
ASEAN University Sports Council
Ministry of Higher Education, Level 2, No. 2, Tower 2, Jalan P5/6, Precinct 5, 62200 Putrajaya, Malaysia
Phone: +603-8870 5185 E-mail: secretariat.ausc@gmail.com