0926e Athlete Medical Information

2014 NVGAG 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: We will not provide routine medical care, replacement medications, replacement equipment or
replacement supplies for pre-existing conditions. Athletes must bring enough medication and medical supplies to
last through the GAMES. Any medication or medical supplies provided on site will be charged back to the
Athlete's medical facility. Narcotic prescriptions will not be filled.
The Veterans Health Care System of the Ozarks (VHSO) has inpatient services. Should a Athlete have a problem
that needs attention or treatment in an Emergency Room or local hospital, please inform a coach or local
organizing committee staff who will notify the local VA medical staff.
Athletes using oxygen must have their sponsoring VA Medical Center coordinate oxygen services, including
supplies, with a local oxygen provider in northwest Arkansas.
Limited medical assistance will be provided 24 hours a day at The Maples dormitory on the University of
Arkansas campus. First aid and medical stabilization at the events and activities will also be provided. Ambulance
care will be provided as needed.
When registering on June 28, 2014, please tell us if there have been any significant changes in your health since
application was completed. These changes include:
•
•
•

Changes in medication
Admissions and/or hospitalizations
New diagnosis, problems, or conditions

Please have your VA Primary Care Provider complete the enclosed Medical Application (VAF 0926e) and submit
it, along with a copy of your VA ID card, with your application packet.

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

ATHLETE NUMBER-OFFICE USE ONLY

ATHLETES 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.

Dear Provider,
Pending approval, the Veteran patient plans to participate in various athletic events and/or games which may be strenuous and/or
dangerous depending on his/her condition. Additionally, should the Veteran patient require personal ADL assistance, please understand
this will not be provided by The Veterans Health Care System of the Ozarks (VHSO) and would be a reason not to clear him/her unless
he/she is accompanied by a caregiver.
DATE

VA MEDICAL CENTER NAME

WHAT IS YOUR VA STATUS
INPATIENT

NAME (Last, First, MI)

OUTPATIENT

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

HEIGHT

DIABETES

HEART FAILURE

HYPERTENSION

OTHER (List below)

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

NO

I HAVE ATTACHED A 12 LEAD EKG (Completed within the last
6 months) (REQUIRED)
YES

BLOOD PRESSURE

NO

I HAVE ATTACHED SLEEP STUDY (Required if using a CPAP/
BIPAP)
YES
NO

LIST ALL ACTIVE MEDICATIONS

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

NO

REASON FOR ADMISSION

LAST ADMISSION
ALLERGIES

IS THE VETERAN VISUALLY IMPAIRED? (Legally blind)

YES

NO

IS THE VETERAN HEARING IMPAIRED?

YES

NO

TETANUS TOXOID DATE
PPD DATE

PLEASE UPDATE TETANUS IF NOT WITHIN 10 YEARS
REQUIRED WITHIN 12 MONTHS

IF POSITIVE, SEND CURRENT CHEST X-RAY REPORT TAKEN
AFTER POSITIVE PPD

IS THE PATIENT FREE OF COMMUNICABLE DISEASES? (If no, explain)

YES

NO

CAN HE/SHE TAKE HIS/HER OWN MEDICATIONS? (If no, explain)

YES

NO

PLEASE ADVISE VETERAN OF THEIR RESPONSIBILITY FOR BRINGING
ENOUGH MEDICATION FOR THE TRIP AND THE WEEK.
THE VETERANS HEALTH CARE SYSTEM OF THE OZARKS (VHSO) 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? (If yes, please provide the name and telephone number of the accompanying caregiver)

YES

NO

IS THE VETERAN INCONTINENT OF BOWEL? (If yes, please provide the name and telephone number of the accompanying caregiver)

YES

NO

CAREGIVER NAME

VA FORM
FEB 2014

0926e

CAREGIVER TELEPHONE NUMBER (Include area code)

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

YES

NO

LIST ANY SPECIAL ASSISTIVE DEVICES THE VETERAN WILL BE USING

IF YES TO ANY ONE OF THE ABOVE QUESTIONS, EQUIPMENT MUST BE INSPECTED AND CERTIFIED BY THEIR
SPONSORING MEDICAL FACILITY.
IS THE VETERAN ON PORTABLE OXYGEN? (If yes, Rx i.e., 2L/min.)

YES

NO

IS THE VETERAN ON CPAP/BIPAP? (If yes, pressure setting)

YES

NO

ATHLETES MUST BRING AND PROVIDE THEIR OWN CPAP/BIPAP
IF YES TO ANY ONE OF THE ABOVE QUESTIONS, SPONSORING VA MEDICAL CENTER MUST COORDINATE OXYGEN
SERVICES, INCLUDING SUPPLIES AND EQUIPMENT, WITH A LOCAL OXYGEN PROVIDER.
LIST SPECIAL NEEDS (e.g. feeding tube, tracheotomy, catheter, mobility, bowel and bladder care, etc.)

LIST THOSE NEEDS WITH WHICH THE VETERAN REQUIRES ASSISTANCE

BEHAVIORAL NEEDS

COGNITIVE NEEDS

IF YES TO ANY ONE OF THE ABOVE QUESTIONS, ACCOMPANYING CAREGIVER MUST BE ABLE TO PROVIDE THE
ASSISTANCE NEEDED.
WHAT ACTIVITY RESTRICTIONS DO YOU RECOMMEND?

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

YES

NO

SWIMMING

YES

NO

TRACK

YES

NO

PLEASE SELECT THE EVENTS THE VETERAN CAN OR CANNOT PARTICIPATE IN
AIR RIFLE

YES

NO

HORSESHOES

YES

NO

BADMINTON

YES

NO

JAVELIN

YES

NO

BOWLING

YES

NO

NINE BALL

YES

NO

CHECKERS

YES

NO

SHOT PUT

YES

NO

DISCUS

YES

NO

SHUFFLEBOARD

YES

NO

DOMINOES

YES

NO

TABLE TENNIS

YES

NO

GOLF

YES

NO

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? (Attach copy)

YES

NO

MEDICAL ORDERS FOR LIFE-SUSTAINING TREATMENT (MOLST)? (Attach copy)

YES

NO

PROVIDER'S NAME (Please print)
MD
PROVIDER'S SIGNATURE

VA FORM 0926e, FEB 2014, page 2

PA

NP

PROVIDER TELEPHONE NUMBER
(June 28 to July 1, 2014)

PROVIDER PAGER NUMBER
(June 28 to July 1, 2014)