Uncontrolled copy not subject to amendment
TG Form 23
MEDICAL DECLARATION FORM
Surname: | Forenames: | Date of Birth: |
Condition being declared: |
Medication being taken: | Name: |
Dosage: | |
Storage requirements: |
Do you carry/need any emergency medication? |
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If Yes give details: |
How are you affected by the condition by normal routine activities? |
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How are you affected by the condition during strenuous exercise? |
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Have you sought advice from your doctor/nurse about your condition in relation to the activity? Yes/No If yes give details of comments/advice given. |
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Any additional information/comments which will help you mange your condition during the activity. |
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If you are proceeding overseas and you have had treatment for an ongoing medical condition in the last 12 months, please give further details: |
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I fully understand that the activities may be strenuous and conducted in environmental conditions such as dust, fumes, extreme temperatures and altitudes that may aggravate my condition. I confirm that I have consulted my doctor if there is any doubt regarding the suitability of the activity or my fitness/ability to take part in the activity. Should there be any change in my condition after signing this declaration, I will inform the Officer in Charge of the activity or the OC Sqn/Wing HQs concerned prior to travelling to the activity.
Signature of participant: | Date: | |
Signed: | Person having parental responsibility for a cadet under 16 years of age) |
PTO
Subsequent condition being declared (if required): |
Medication being taken: | Name: |
Dosage: | |
Storage requirements: |
Do you carry/need any emergency medication? |
|
If Yes give details: |
How are you affected by the condition by normal routine activities? |
|
How are you affected by the condition during strenuous exercise? |
|
Have you sought advice from your doctor/nurse about your condition in relation to the activity? Yes/No If yes give details of comments/advice given. |
|
|
Any additional information/comments which will help you mange your condition during the activity. |
|
|
If you are proceeding overseas and you have had treatment for an ongoing medical condition in the last 12 months, please give further details: |
|
|
I fully understand that the activities may be strenuous and conducted in environmental conditions such as dust, fumes, extreme temperatures and altitudes that may aggravate my condition. I confirm that I have consulted my doctor if there is any doubt regarding the suitability of the activity or my fitness/ability to take part in the activity. Should there be any change in my condition after signing this declaration, I will inform the Officer in Charge of the activity or the OC Sqn/Wing HQs concerned prior to travelling to the activity.
Signature of participant: | Date: | |
Signed: | Person having parental responsibility for a cadet under 16 years of age) |
Revision 1.03