Sports Fitness Medical Certificate

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Health Center - University of Peradeniya

Sports fitness MC (යෝග්‍යතා සහතිකය)

REG

Details of the Players

Name :-...................................................................................................
Address :-...................................................................................................
N.I.C No :-....................................... Gender:-........................
Date of Birth :-....................................... Age:-.........................
Sports /s :-...................................................................................................

Conclusion of the Physician

Athlete doesn't have any physical or mental contraindication or refrain from the sport / physical activity requested at the time of the Medical Examination therefore.

Cleared for Participation
No participation
Need referral

Special Notes

A. Medical Notes

1).....................................................................................
2).....................................................................................
3).....................................................................................

B. Remarks

Notes to the Physiotherapist/Nutritionist..............................
Notes to Master in charge in sports........................................
Notes to Coach............................................................................
Other Notes................................................................................
Date for the next visits.................................................................
Medical Officer
Rubber Stamp
Date

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Introductions to Athlete

1. This document belongs to the athlete and nontransferable Valid for one year period ahead from the date of issue.

2. After the expiry date of PPE, athlete must for the periodic health evaluation.

3. Submit a copy of the Original to the event organizers, certified by the head of the institute.

4. If an Athlete meets any of serious medical illness, accident or a hospitalization, he or she should consult for a Re-medical examination.

5. Athlete must have obtained the pre-participation medical certificate (PPE) in a prior situation to under go a pre-event medical examination

6. Even after a thorough medical examination there are rare causes that can cause sudden death to an athlete. (Eg. Cardiomyopathy, ARVD, Heart strokes)

Pre Event Fitness

පූර්ව ක්‍රියා යෝග්‍යතා සහතිකය ලබාගෙන ඇත්නමි පමණක් සුදුසුකමි ලත් නිලධාරියකු මඟින් තරඟයක් සඳහා පමණක් වලංගු වන පහත සඳහන් පූර්ව තරඟ යෝග්‍යතා සහතිකය තරඟයට සහභාගි වීමට පෙර ලබාගත හැක.

Event/Sport ............ ............ ............ ............ ............
Date of the Event/Sport ............ ............ ............ ............ ............
History
Fever (Within 3 days)
Diarrhoea (Within 3 days)
Other		 Yes/No Yes/No Yes/No Yes/No Yes/No
Yes/No Yes/No Yes/No Yes/No Yes/No
Yes/No Yes/No Yes/No Yes/No Yes/No
.............................
CVS
Pulse
B P
Auscultation		 ............ ............ ............ ............ ............
............ ............ ............ ............ ............
............ ............ ............ ............ ............
RES (Normal/Abnormal)
Musculo Skeletal System
(Normal/Abnormal)
CNS (Normal/Abnormal)
Abdomen (Normal/Abnormal)
Athlete doesn't Have any physical or mental contraindication or refrain from the requested sports competition at the time of the medical examination
Athlete is not fit for the competition
Signature and rubber stamp of
Medical Officer		 ............ ............ ............ ............ ............
Name of the Medical Officer ............ ............ ............ ............ ............
Date

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