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TEAM PRE-BOUT MEDICAL STATEMENT Team Manager Name: Team: I certify that all boxers in the team adhere to the AIBA Medical Commission Guidelines for disqualifying conditions and are medically fit to box according to AIBA regulations in Smithfield BoxFest 2016. To be signed and given to the organising committee at weigh-in. Boxer’s Signature: Date: Team Manager’s signature: AIBA Medical Commission Guidelines for disqualifying conditions are “evidence of or disclosed history of the following conditions in an annual and/or pre-bout examination”: Acute and chronic infections Severe blood dyscrasias Sickle cell disease or trait History of Hepatitis B, Hepatitis C or HIV infection Smithfield BoxFest 2016 Refractive and intraocular surgery, cataract, retinal detachment Myopia of more than -3.50 dioptres Recorded visual acuity in each eye of:uncorrected worse than 20/200 or corrected worse than 20/60 Exposed open infected skin lesions Significant congenital or acquired cardiovascular and pulmonary abnormalities Significant congenital or acquired musculoskeletal deficiencies Unresolved post-concussion symptoms, which will need clearance from a neurologist Significant psychiatric disturbances or drug abuse Significant congenital or acquired intracranial mass lesions or bleeding Any seizure activity within the last 3 years Hepatomegaly, splenomegaly, ascites Pregnancy Uncontrolled diabetes mellitus or uncontrolled thyroid disease Any implantable device which can alter any physiologic process Women’s breast protector which protects any thing other that the breast protuberance itself Conditions that are not Disqualifying to Box: Deafness (but Competition jury must be made aware) Smithfield BoxFest 2016