0926e Athlete Medical Information

MEDICAL CLEARANCE INSTRUCTIONS FOR ATHLETES
You must be seen by your VA Primary Care Provider to be
medically cleared to participate in the Games.
Reminder: Medical assistance is not intended for pre-existing conditions. Competitors must bring with them
enough medication and medical supplies to last throughout the Games. There are no provisions for providing
replacement medications and medical supplies. We will not refill any narcotic prescriptions.
Medical assistance will be provided 24 hours a day as part of the National Veterans Golden Age Games.
Sick call and emergency medical treatment will be available at the
First aid and patient stabilization will be provided at the events and activities. Ambulances will be called if
emergency care is needed.
Competitors using oxygen must have their sponsoring VA Medical Center coordinate oxygen services, including
supplies, with a local oxygen provider.
When you check-in for the Games, you must tell us if there have been any significant changes in your health since
you completed your application. These include:
· Changes in medication
· Admissions/Hospitalizations
· New diagnosis, problems, or conditions
We need current addresses and phone numbers for:
·
·
·
·
·

You
Next of Kin
Emergency Contact Person
Your Primary Care Provider
Sponsoring Facility Point of Contact

Please have your VA Primary Care Provider complete the General
Medical Information/Medical Form VA 0926e attached .

.

ATHLETE NUMBER-OFFICE USE ONLY

OMB Number:
Respondent Burden: 20 minutes

ATHLETE MEDICAL INFORMATION
A PHYSICIAN, NURSE PRACTIONER OR PHYSICIAN ASSISTANT MUST FILL OUT AND SIGN THIS FORM

PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17, Section 1710. VA
may disclose the information that you put on this form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in
the Privacy Act systems of records notices identified as 121VA19 “National Patient Databases - VA”. Providing the requested information is
voluntary. However, you will not be able to participate in the event without furnishing this information.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond
to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this
application will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.
DATE

VA MEDICAL CENTER NAME

NAME (Last, First, MI)

ADDRESS (Street, City, State, Zip Code)

SOCIAL SECURITY NO. VETERANS DATE
(Last 4 digits only)
OF BIRTH

AGE

PLEASE REVIEW VETERAN DEMOGRAPHICS FOR ACCURACY BEFORE YOU COMPLETE THIS FORM.
WEIGHT

PROBLEM LIST (Active Problems)
COPD

HEART FAILURE

HYPERTENSION

DIABETES

I HAVE REVIEWED THE ACTIVE PROBLEMS
AND CONFIRM THAT THIS LIST IS
CURRENT

HEIGHT

YES

NO

BLOOD PRESSURE
LIST ALL ACTIVE MEDICATIONS

I HAVE REVIEWED THE ABOVE
MEDICATIONS AND THE VETERAN IS
TAKING THEM AS DIRECTED
YES

NO

LAST ADMISSION
ALLERGIES
IS THE VETERAN VISUALLY IMPAIRED? (Legally blind)

YES

NO

IS THE VETERAN HEARING IMPAIRED?

YES

NO

YES

NO

YES

NO

IF POSITIVE, SEND CURRENT X-RAY REPORT

YES

NO

CAN HE/SHE TAKE HIS/HER OWN MEDICATIONS?

YES

NO

TETANUS TOXOID DATE
PPD DATE

PLEASE UPDATE TETANUS IF NOT WITHIN 10 YEARS
WITHIN 12 MONTHS

PLEASE ADVISE VETERAN OF THEIR RESPONSIBILITY FOR BRINGING
ENOUGH MEDICATION FOR THE TRIP AND THE WEEK.
THE HOST VA MEDICAL CENTER WILL NOT PROVIDE NARCOTIC REFILLS FOR ANY REASON.
The cost of any medical expenses and/or medications will be charged back to the veteran or the veteran's originating facility.
DOES THE VETERAN NEED ASSISTANCE WITH THE FOLLOWING ADL'S?
AMBULATION

TRANSFER

FEEDING

GROOMING

TOILETING

IS THE VETERAN INCONTINENT OF URINE?

YES

NO

IS THE VETERAN INCONTINENT OF BOWEL?

YES

NO

IF THE VETERAN USES A WHEELCHAIR, CAN HE/SHE TRANSFER WITHOUT ASSISTANCE?

YES

NO

YES

NO

LIST ANY DURABLE MEDICAL EQUIPMENT OR SPECIAL ASSISTIVE DEVICES THE VETERAN WILL BE USING

IS THE VETERAN ON PORTABLE OXYGEN? (If yes, Rx i.e., 2L/min.)
VA FORM
APR 2010

0926e

Adobe LiveCycle Designer

LIST SPECIAL NEEDS (e.g. feeding tube, tracheotomy, catheter, mobility, bowel and bladder care, etc.)

LIST THOSE NEEDS THAT THE VETERAN REQUIRES ASSISTANCE WITH

BEHAVIORAL NEEDS

COGNITIVE NEEDS

WHAT ACTIVITY RESTRICTIONS DO YOU RECOMMEND?

IS THE VETERAN IS PHYSICALLY CAPABLE OF PARTICIPATING IN THESE AEROBIC EVENTS?
CYCLING

SWIMMING

PLEASE CHECK THE EVENTS THE VETERAN CAN PARTICIPATE IN
AIR RIFLE

CROQUET

GOLF

SHOT PUT

BOWLING

DISCUS

HORSESHOES

SHUFFLEBOARD

CHECKERS

DOMINOES

NINE-BALL

TABLE TENNIS

IN YOUR OPINION, CAN THE VETERAN MAKE THE TRIP AND PARTICIPATE IN THE NATIONAL VETERANS GOLDEN
AGE GAMES?

YES

NO

DOES THE VETERAN HAVE AN ADVANCED DIRECTIVE?

YES

NO

PROVIDER'S NAME (Please print)
MD

PROVIDER'S SIGNATURE

PROVIDER TELEPHONE NUMBER
(Where you can be reached during the Games)

VA FORM 0926e, APR 2010, page 2

PROVIDER PAGER NUMBER
(Where you can be reached during the Games)

PA

NP