0927c Participant Registration Form-Physical Exam, National Ve

OMB Number:
Respondent Burden: 20 minutes

PARTICIPANT REGISTRATION FORM -- PHYSICAL EXAM
NATIONAL VETERANS TEE TOURNAMENT
(To be completed by a Clinician. 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 20 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the forms.
Dear Examining Clinician: Your patient is planning to participate in a three-day event with moderately strenuous, sporting activities,
provided that you concur. To ensure that this is an appropriate activity for this Veteran, please conduct a detailed review of his/her
medical record. Thank you for assisting us in ensuring this participant's safety.
PATIENT'S NAME
SOCIAL SECURITY
DATE
NUMBER (Last 4 digits only)

PRIMARY DISABILITY/DIAGNOSIS: DATE OF ONSET
VISUALLY IMPAIRED
LEGALLY BLIND

TOTALLY BLIND

SPINAL CORD INJURY (SCI)

RESIDUAL VISION
COMPLETE

- LEVEL

INCOMPLETE

PARAPLEGIC
QUADRIPLEGIC
MULTIPLE SCLEROSIS (MS)
HEAD INJURY
CVA WITH RESIDUAL
AMPUTEE

RIGHT LEG, A/K, B/K

RIGHT ARM, A/E, B/E

LEFT LEG, A/K, B/K

LEFT ARM, A/E, B/E

OTHER

PSYCHOLOGICAL CONDITIONS
PTSD

ANXIETY

DEPRESSION

SEIZURES

STROKE

OTHER CONDITION(S)
PLEASE RATE YOUR PATIENTS LEVEL OF INDEPENDENCE
INDEPENDENT WITH SELF CARE NEEDS, INDEPENDENT ONCE ORIENTED
INDEPENDENT WITH SELF CARE NEEDS, NEEDS SIGHTED GUIDE OCCASIONALLY AFTER ORIENTATION
INDEPENDENT WITH SELF CARE NEEDS, NEEDS SIGHTED GUIDE CONTINUOUSLY
PATIENT NEEDS
PATIENT REQUIRES ATTENDANT?

YES

NO IF YES, ATTENDANTS' NAME

USES WHEELCHAIR MAJORITY OF TIME?

YES

NO

USES OTHER ADAPTIVE EQUIPMENT?

YES

NO

VA FORM
APR 2010

0927c

IF YES, WHAT
Adobe LiveCycle Designer

PATIENT'S NAME

SOCIAL SECURITY NUMBER
(Last 4 digits only)

MEDICAL HISTORY (i.e., diabetes, heart disease, hypertension, respiratory difficulty)

LIST ALL MEDICATIONS, INCLUDING ASPIRIN AND OTHER "OVER THE COUNTER" MEDICINE/SUPPLEMENTS

KNOWN ALLERGIES
DATE OF LAST TETANUS SHOT

IS THE PATIENT TAKING COUMADIN
OR OTHER ANTICOAGULANTS?

YES

NO IF YES, WHICH

DOES THE PATIENT SMOKE?

YES

NO

ALCOHOL OR OTHER SUBSTANCE USE?

YES

NO

PHYSICAL EXAM
HEIGHT

(inches) WEIGHT

(pounds) PULSE

CARDIAC

BLOOD PRESSURE

HEAD & NECK

PULMONARY

ABDOMEN

EXTREMITIES

HEENT

NEURO

OTHER FINDINGS

IN MY OPINION, THE ABOVE INDIVIDUAL:
IS MEDICALLY FIT TO PARTICIPATE

IS NOT MEDICALLY FIT TO PARTICIPATE

SIGNATURE OF EXAMING CLINICIAN

NAME OF EXAMING CLINICIAN (Please print)

ADDRESS OF EXAMINING CLINICIAN

TELEPHONE NUMBER

VA FORM 0927c, APR 2010, page 2