0925b General Medical Form

OMB Number: 2900-0759
Expiration Date: Xxx, 20XX
Respondent Burden: 10 minutes

ATHLETE NUMBER-OFFICE USE ONLY

GENERAL MEDICAL FORM
TO BE COMPLETED BY PARTICIPANT. PLEASE TYPE OR PRINT CLEARLY.

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 10 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)

E-MAIL ADDRESS
SOCIAL SECURITY NO.
(Last 4 digits only)

AGE

DAYTIME TELEPHONE
NUMBER (Include area code)

CELL PHONE NUMBER
(Include area code)

EVENING TELEPHONE
NUMBER (Include area code)

TEAM COORDINATOR/LEADER:

ALTERNATE TEAM CONTACT:

TELEPHONE NUMBER

TELEPHONE NUMBER

E-MAIL ADDRESS

In Case of Emergency, Notify (Name):
TELEPHONE NUMBER

E-MAIL ADDRESS

ADDRESS (Street, City, State and Zip Code)

RELATIONSHIP TO PATIENT

TO BE COMPLETED BY THE EXAMINING PHYSICIAN. PLEASE TYPE OR PRINT CLEARLY.
Dear Doctor: Your detailed exam of the participant will be very helpful to the medical assistance team. If an assistant completes the
form, please countersign the exam.
OPERATIONS (Please list)

ALLERGIES (Are you allergic to anything? If yes, specify)

1

1

2

2

3

YES

NO

3

DIAGNOSIS/TYPE OF INJURY

VA IDENTIFICATION CARD

DATE OF INJURY OR DIAGNOSIS
SPINAL CORD INJURY (SCI)--LEVEL OF INJURY
MULTIPLE SCLEROSIS (MS)
AMPUTEE

PLEASE ATTACH A COPY OF
VA IDENTIFICATION CARD HERE
(See below)

HEAD INJURY
OTHER (Please specify)

If you do not attach a copy of your VA IDENTIFICATION CARD you must
fill out VA Form 10-10EZ including your full Social Security Number.

MEDICATIONS (Please list all medications you are currently using. If you require more room, please attach an additional sheet.)
DOSAGE
MEDICATION NAME
1
2
3
4
5
OTHER MEDICAL INFORMATION (Please list all other medical information concerning your current health status.)
1
2
VA FORM
FEB 2014

0925b

HOW OFTEN TAKEN

PHYSICAL FORM
WEIGHT

BLOOD PRESSURE

HEAD & NECK

LUNGS

ABDOMEN

HEART

EXTREMETIES

SKIN

OTHER FINDINGS

PRESENT AND PAST MEDICAL HISTORY (Diabetes, heart disease, hypertension, etc.)

IS THE PATIENT ON DIALYSIS?* (Patient is responsible for setting up any dialysis treatment needed)

YES

NO

IS THE PATIENT ON A VENTILATOR?

YES

NO

IS THE PATIENT ON ANTICOAGULANT DRUGS? (If yes, which)

YES

NO

PHYSICIAN CLEARANCE
IN MY OPINION, THE ABOVE INDIVIDUAL (You must check on e of the following boxes)
IS CLEARED TO COMPETE OR

IS NOT CLEARED TO COMPETE

IF NOT CLEARED, REASON WHY

PHYSICIAN INFORMATION

NVWG AND/OR USQRA CLASSIFICATION CARD(S)

NAME OF EXAMINING PHYSICIAN (Please print)
ADDRESS (Street, City, State and Zip Code)

PLEASE ATTACH A COPY OF YOUR
CLASSIFICATION CARD(S)
(See below)

SIGNATURE OF EXAMINING PHYSICIAN
TELEPHONE NUMBER

If applicable, please attach a copy (not the original) of you
National Veterans Wheelchair Games, USQRA (quad rugby), and/
or Wheelchair Sports, USA classification card above.

DATE

May omit only if copy of current NVWG Classification card is stapled in the area provided in the General Medical Information Section on Page 1 of
this form.
This section must be completed by someone familiar with direct muscle testing, i.e., a physician, physical therapist, kinesiotherapist, or occupational
therapist.
NEURO EXAM (Manual muscle test, 0-5)
UPPER EXTREMITY

RIGHT

LEFT

LOWER EXTREMITY

DELTOID

HIP FLEXION

BICEPS

HIP EXTENSION

WRIST EXTENSION

HIP ADDUCTION

WRIST FLEXION

HIP ABDUCTION

TRICEPS

KNEE FLEXION

FINGER EXTENSION

KNEE EXTENSION

FINGER FLEXION

DORSIFLEXION

FINGER ABD/ADD

PLANTARFLEXION

SITTING BALANCE (Please check one)

NORMAL

FAIR

POOR

NONE

VA FORM 0925b, FEB 2014, page 2

HANDEDNESS (Please check one)

RIGHT

LEFT

TRUNK (0-5 scale)
ABDOMINALS
SPINAL EXTENSORS

RIGHT

LEFT

UPPER

LOWER