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AUTORISATION DE SOINS EN CAS D’ACCIDENT
SURVENANT A UN LICENCIE MINEUR
JOUEUR MINEUR :
Nom : Prénom : Date de naissance :
Adresse :
N° Sécurité Sociale :
ASSOCIATION: ECOLE DE RUGBY DU PIC SAINT LOUP
SAINT CLEMENT DE RIVIERE
En castd’accident, en fonction des soins nécessaires, le responsable fera appel ■
* soit au médecin de l’association *soit a votre médecin traitant
soit au pompier soit au SAMU
♦> soit au secours portables 0 112
et vous préviendra le plus rapidement possible
Pour cela merci de préciser les renseignements suivants :
PERE E.............. MERE 1:2............... AUTRE 3.........
Numéro de téléphone de votre voisin, ami ou famille :
NOM .............................. ............................
Médecin traitant : DOCTEUR ........................ ..........................
Etablissement de soins choisi :
HOPITAL ....................................... . .........................
CLINIQUE ........................................ .....................
Ce choix sera bien sur respecté dans la mesure où l’établissement d’accueil
sera compatible avec l’état de l’enfant ou de l’adolescent
■Jesoussigné MONSIEUR
MADAME ..........................................................................
Autorise tout examen, soin ou intervention chirurgicale nécessaire, et
autorise le responsable de l'association :
sà demander l’admission en établissement de soins
• à reprendre l’enfant à sa sortie en cas d’indisponibilité absolue des
parents
Date ................. Signature du père, de la mère ou du responsable légal
FICHE INDISPENSABLE POUR TOUTE ADMISSION DANS UN ETABLISSEMENT DE SOINS
FICHE MEDICALE
NOM : PRENOM :
Date de naissance :
EXAMEN CLINIQUE
APPAREIL CARDIO-VASCULAIRE :
Fréquence cardiaque :
Rythme cardiaque
Tension artérielle
Pouls fémoraux
Auscultation cardiaque :
□ régulier
bras droit :
[] normaux
□Irrégulier
bras gauche :
normale
J souffle diastolique 0 souffle systolique
souffle continu
ü Auscultation pulmonaire : normale
[] Antécédents d’allergies et/ou d’asthme
APPAREIL LOCOMOTEUR :
Muscles paroi abdominale :
Palpation des orifices herniaires
Déformations ostéo-articulaires :
Genu varum, Genu valgum, pieds plats, scoliose, cyphose, hyper lordose
Recherche des épiphysites de croissance :
Tubérosité tibiale
Colonne dorsale
Pointe de la rotule
□ Insertion calcanéenne du tandon d’Achille
ANTECEDENTS :
Médicaux
Chirurgicaux
accidents sportirs
VACCINATIONS :
Tétanos u Hépatite B u
Cachet du médecin
Date

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Fiche médicale et autorisation de soins

  • 1. AUTORISATION DE SOINS EN CAS D’ACCIDENT SURVENANT A UN LICENCIE MINEUR JOUEUR MINEUR : Nom : Prénom : Date de naissance : Adresse : N° Sécurité Sociale : ASSOCIATION: ECOLE DE RUGBY DU PIC SAINT LOUP SAINT CLEMENT DE RIVIERE En castd’accident, en fonction des soins nécessaires, le responsable fera appel ■ * soit au médecin de l’association *soit a votre médecin traitant soit au pompier soit au SAMU ♦> soit au secours portables 0 112 et vous préviendra le plus rapidement possible Pour cela merci de préciser les renseignements suivants : PERE E.............. MERE 1:2............... AUTRE 3......... Numéro de téléphone de votre voisin, ami ou famille : NOM .............................. ............................ Médecin traitant : DOCTEUR ........................ .......................... Etablissement de soins choisi : HOPITAL ....................................... . ......................... CLINIQUE ........................................ ..................... Ce choix sera bien sur respecté dans la mesure où l’établissement d’accueil sera compatible avec l’état de l’enfant ou de l’adolescent ■Jesoussigné MONSIEUR MADAME .......................................................................... Autorise tout examen, soin ou intervention chirurgicale nécessaire, et autorise le responsable de l'association : sà demander l’admission en établissement de soins • à reprendre l’enfant à sa sortie en cas d’indisponibilité absolue des parents Date ................. Signature du père, de la mère ou du responsable légal FICHE INDISPENSABLE POUR TOUTE ADMISSION DANS UN ETABLISSEMENT DE SOINS
  • 2. FICHE MEDICALE NOM : PRENOM : Date de naissance : EXAMEN CLINIQUE APPAREIL CARDIO-VASCULAIRE : Fréquence cardiaque : Rythme cardiaque Tension artérielle Pouls fémoraux Auscultation cardiaque : □ régulier bras droit : [] normaux □Irrégulier bras gauche : normale J souffle diastolique 0 souffle systolique souffle continu ü Auscultation pulmonaire : normale [] Antécédents d’allergies et/ou d’asthme APPAREIL LOCOMOTEUR : Muscles paroi abdominale : Palpation des orifices herniaires Déformations ostéo-articulaires : Genu varum, Genu valgum, pieds plats, scoliose, cyphose, hyper lordose Recherche des épiphysites de croissance : Tubérosité tibiale Colonne dorsale Pointe de la rotule □ Insertion calcanéenne du tandon d’Achille ANTECEDENTS : Médicaux Chirurgicaux accidents sportirs VACCINATIONS : Tétanos u Hépatite B u Cachet du médecin Date