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4TH Annual WOUNDED WARRIOR TENNIS CampFor Wounded, Ill, and Injured Service Members and VeteransMay 18 - 24, 2015 (Travel Dates: May 18 & 24)To ensure legibility, please type your answers and be sure to answer ALL questions!CONTACT INFORMATION:Name of Participant as it appears on DL/passport: NicknameCurrent Mailing Address: City State ZipPermanent Address (if different from above)Telephone Numbers: Home:Cell:Email Address: Height: Weight: DOB:Gender:MaleFemaleHometown:Emergency Contacts:RelationshipHome PhoneCell Phone(1)(2)MILITARY SERVICE INFORMATION:Military status:Active DutyBranch of Service:VeteranUSNReservistUSMCUSAUSAFOther:Years of Active Duty: Date of Separation from Active Duty:Rank: Deployment Experience:Were you injured post-9/11?YesWere you injured in combat post-9/11?OIFOEFOther:NoYesNoDISABILITY/MEDICAL INFORMATION:What is your disability?Date of Onset:Current Medications:What are they for?DosageChanges to your medications in the last 3 months?(1)(2)(3)(4)(5)(6)Last Name: Tennis Camp 2015 1/7
DISABILITY/MEDICAL INFORMATION (cont.):Do you have seizures?YesNoIf yes, date of last seizure and type of seizureFrequency of seizures:Do you have diabetes?YesNoType 1Type 2Please list any allergies you may have:Are any of your body parts susceptible to cold, heat, and /or impact?YesNoIf yes, please list:Do you have any cardiac problems? If yes, please describe.Do you experience pain?YesNoPercentage of time you are in pain: On scale of 1-10, what level of pain are you in?Where is your pain located?Ability to speak:IntactImpairedHearing:IntactImpairedHearing aids?Vision:IntactImpairedDo you wear:Do you have any diet restrictions/ allergies?YesYesNoglassesNocontactsPlease describe:Do you experience any sleep disorders? Snoring Sleep walking Sleep apneaHow many hours a night do you sleep (average)?Do you have decreased strength in your upper extremities (arms)?YesNo If yes, what sideWill you need any type of adaptation device to hold racket e.g. Ace wraps/athletic tape?Are you left or right hand dominant?LeftYesNoRightDo you have any upper extremity (arm) limitation that may affect your participation?YesNoIf yes, where and what extent?COMBAT STRESS/PTSD/MST (Military Sexual Trauma)Do you have panic attacks?YesAre you sensitive to loud noises?NoYesDo you have flashbacks?NoYesDo crowds make you feel anxious?Do you get angry easily?YesNoAre you hyper-vigilant?Do you isolate yourself?YesNoDo you get anxious easily?YesYesNoYesNoNoNoHow can we best support you should you become anxious, fearful, angry, etc?Last Name: Tennis Camp 2015 2/7
TRAUMATIC BRAIN INJURY (TBI)YesHave you sustained traumatic brain injury?Status of injury:Primary DisabilitySecondary ConditionWhat is the cause of your TBI?Blast injuryDo you wear a helmet?NoSeverity of Injury?:YesMildNoModerateDate of injury:Motorcycle/Vehicle accidentOtherSevereHas your TBI affected you in any if the following ways?Short-term memory impairmentYesNoDecreased attention spanYesNoProblem-solving difficultiesYesNoInability to concentrateYesNoImpulsive/Decreased ability to filter what I say and/or doDecreased balanceYesNoVestibular impairmentYesNoLight sensitivityYesNoDo you get motion sickness?YesNoDo you have difficulty walking?YesNoDo you have difficulty running?YesNoDo you get dizzy?YesNoNoYesPlease explain the items you have checked yes to:Do you have headaches?YesNoHow often do they occur? What triggers your headaches?On a scale of 1 to 10, how severe are your headaches?How do you treat your headaches?MedicationRestOtherMENTAL HEALTHDo you have a mental health disorder?If yes, please specify:BipolarYesDepressionNoAdjustment DisorderSchizophreniaOther:Last Name: Tennis Camp 2015 3/7
AMPUTATIONStatus of Injury:Primary DisabilitySecondary ConditionDate of Amputation: Level of Amputation:Please describe your means of mobility (i.e. prosthesis, wheelchair, none, etc.)If you have prosthesis, will you be using it while taking part in our program?YesNoDURABLE MEDICAL SUPPLIESDo you use mobility devices?WheelchairWalkerYesNoCaneIf yes, which devices do you use:CrutchesAre you able to push yourself in a wheelchair?Do you use a shower chair?Do you need a shower chair?YesNoYesProstheticYesOrthoticOtherNoIf yes, will you be bringing your own?YesNoNoSPINAL CORD INJURY (SCI)ParaShuntQuadCompleteIncompleteAre you able to transfer out of wheelchair?Concerns with pressure sores/skin breakdownYesNoConcerns with muscle spasmsPlease describe any other medical conditions not mentioned in any of the sections above:TENNIS EXPERIENCEDo you need to borrow a tennis wheelchair?What level of tennis do you play?YesBeginnerNoIntermediateDid you play tennis before injury or diagnoses?Do you currently play tennis?YesWill you bring your own?YesNoYesNoAdvancedNoIf yes, how many times in the last year?MERCHANDISET-shirt size:SmallMediumLargeX-LargeXX-LargeTennis shoe size:Last Name: Tennis Camp 2015 4/7
CARE PROVIDER (IF NEEDED) INFORMATIONPlease explain why you need a Care Provider:Care Provider Name: DOB:Cell Number:Email:Will Care Provider be participating in the camp?T-Shirt Size:SmallMediumNoYesLargeXX-LargeX-LargeTennis shoe size:Will you be bringing a service animal?YesNoAnimal type:Name:FLIGHT INFORMATIONDeparture Airport:Will you need an aisle chair?YesNoReturn Airport:Are you travelling by yourself?YesNoHow did you learn about this camp?Have you participated in this camp before?YesNo201220132014Please tell us in a few sentences why you are interested in attending this camp.Last Name: Tennis Camp 2015 5/7
Medical Clearance Form for Active Duty & VeteransPlease obtain approvals from all physicians and therapists you are seeing,as well as your Chain-of-Command if on active duty.Applicant’s Name Phone # Unit if active dutyEvent Name: 4th Annual Wounded Warrior Tennis Camp Dates: May 18-24, 2015Location: San Diego, CA 92104Medical POC: Marla Knox, CTRS, MA Phone: 619-532-5783 Email: marla.knox@med.navy.milInformation about this event is available at www.sdwoundedwarriortennis.orgPRIMARY CARE PHYSICIAN’S AUTHORIZATIONName of Primary Care Provider Phone #Primary Care Provider Signature DateMENTAL HEALTH THERAPIST’S AUTHORIZATIONName of Mental Health TherapistPhone #Mental Health Therapist’s SignatureDateRECREATION THERAPIST’S AUTHORIZATIONName of Recreation Therapist Phone #Recreation Therapist’s SignatureDatePHYSICAL THERAPIST’S AUTHORIZATIONName of Physical Therapist Phone #Physical Therapist’s SignatureDateCHAIN-OF-COMMAND AUTHORIZATIONName of Officer-in-Charge Phone #Officer-in-Charge SignatureDateLast Name: Tennis Camp 2015 6/7
Please provide proof of military service (one of the following three)Copy of active duty or retired ID cardCopy of first page of DD-214Copy of VA health system ID cardPlease send the completed typed application form, medical clearance form, and proof of military service to:Mary Alice (M. A.) HillierTennis Camp CoordinatorEmail: tennisma@cox.netFax: 619-390-5684Please direct any questions to M.A. Her cell phone is 619-884-8911.Please keep in mind she is in the Pacific Standard Time zone.Last Name: Tennis Camp 2015 7/7
Annual Wounded Warrior Tennis Camp Dates: May 18-24, 2015 Location: San Diego, CA 92104 Medical POC: Marla Knox, CTRS, MA Phone: 619-532-5783 Email: marla.knox@med.navy.mil. Information about this event is available at www.sdwoundedwarriortennis.org _
