{"id":26051269,"date":"2026-08-04T17:23:45","date_gmt":"2026-08-04T15:23:45","guid":{"rendered":"https:\/\/laboucledeletoile.com\/?page_id=26051269"},"modified":"2026-08-04T18:44:20","modified_gmt":"2026-08-04T16:44:20","slug":"medical-record","status":"publish","type":"page","link":"https:\/\/laboucledeletoile.com\/en\/medical-record\/","title":{"rendered":"Medical record"},"content":{"rendered":"

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Merci, vos informations ont bien \u00e9t\u00e9 transmises au service m\u00e9dical.<\/p>\n

\n

 <\/p>\n

” submit_button_text=”Send” _builder_version=”4.27.7″ _module_preset=”default” _unique_id=”9173b411-ef5e-4bd6-8688-bf80ab7f4edd” form_field_background_color=”#FFFFFF” form_field_text_color=”#383838″ form_field_font_size=”16px” form_field_line_height=”1.4em” display_conditions=”W3siaWQiOiI4Y2Q0NGJjNi02ZDZmLTQ0MjYtOTZiNi0yMTk1NWUxMzljN2MiLCJjb25kaXRpb24iOiJsb2dnZWRJblN0YXR1cyIsImNvbmRpdGlvblNldHRpbmdzIjp7ImRpc3BsYXlSdWxlIjoibG9nZ2VkSW4iLCJhZG1pbkxhYmVsIjoiU3RhdHV0IGRlIGNvbm5leGlvbiIsImVuYWJsZUNvbmRpdGlvbiI6Im9uIn0sIm9wZXJhdG9yIjoiT1IifV0=” custom_padding=”||||false|false” admin_email_subject=”Fiche m\u00e9dicale la boucle de l’\u00e9toile” admin_email_from_name=”La Boucle de l’\u00c9toile” use_success_button=”on” success_button_text=”Retour vers votre espace coureur” success_button_url=”https:\/\/laboucledeletoile.com\/user\/” field_label_size=”16px” dipi_enable_conditional_display=”on” dipi_conditional_display_login_status=”{%22logged_in%22:true}” border_radii=”on|3px|3px|3px|3px” box_shadow_style=”preset6″ box_shadow_blur=”44px” box_shadow_spread=”-22px” box_shadow_color=”#383838″ locked=”off” global_colors_info=”{}”][et_pb_contact_field field_id=”Titre_1″ fullwidth_field=”on” _builder_version=”4.27.7″ _module_preset=”default” use_field_html=”on” field_htmlcontent=”<\/p>\n

1 – Informations personnelles<\/span><\/h2>\n
\n

<\/h2>\n

” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Prenom” field_title=”First name” _builder_version=”4.27.7″ use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” 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WhatsApp:” _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Email” field_title=”E-mail address” field_type=”email” _builder_version=”4.27.7″ use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” 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_builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” field_description=” (Nom, lien, t\u00e9l\u00e9phone)” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Titre_2″ fullwidth_field=”on” _builder_version=”4.27.7″ _module_preset=”default” use_field_html=”on” field_htmlcontent=”<\/p>\n

2 – Informations m\u00e9dicales g\u00e9n\u00e9rales<\/span><\/h2>\n
\n

<\/h2>\n

” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Groupe_sanguin” field_title=”Blood type:” _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Pathologies_chroniques” field_title=”Chronic conditions (heart disease, diabetes, respiratory conditions, etc.):” _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Allergies_connues” field_title=”Known allergies:” _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Vaccins_\u00e0_jour” field_title=”Up-to-date vaccinations:” field_type=”select” select_options=”%91{%22value%22:%22NO%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22YES%22,%22checked%22:0,%22dragID%22:-1}%93″ _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Traitements_m\u00e9dicaux_en_cours” field_title=”Current medical treatments:” _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Ant\u00e9c\u00e9dents_m\u00e9dicaux” field_title=”Significant medical or surgical history:” _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Allergies_titres” fullwidth_field=”on” _builder_version=”4.27.7″ _module_preset=”default” use_field_html=”on” field_htmlcontent=”<\/p>\n

Allergies graves et urgences vitales<\/span><\/h1>\n

” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Titre_3″ fullwidth_field=”on” _builder_version=”4.27.7″ _module_preset=”default” use_field_html=”on” field_htmlcontent=”<\/p>\n

3 -Informations sportives<\/span><\/h2>\n
\n

<\/h2>\n

” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Fr\u00e9quence_d\u2019activit\u00e9” field_title=”Frequency of physical activity:” field_type=”select” select_options=”%91{%22value%22:%22Episodic%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%22Monthly%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Weekly%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Daily%22,%22checked%22:0,%22dragID%22:-1}%93″ _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Discipline_principale” field_title=”Primary discipline:” required_mark=”off” _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Exp\u00e9rience” field_title=”Experience in Trail Running \/ Ultra Running \/ Marathon Running:” required_mark=”off” fullwidth_field=”on” _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”\u00c9v\u00e9nements_similaires” field_title=”Similar events that have already taken place:” required_mark=”off” fullwidth_field=”on” _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Titre_4″ fullwidth_field=”on” _builder_version=”4.27.7″ _module_preset=”default” use_field_html=”on” field_htmlcontent=”<\/p>\n

4 – \u00c9tat de sant\u00e9 actuel<\/span><\/h2>\n
\n

<\/h2>\n

” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Blessures_r\u00e9centes” field_title=”Recent injuries:” required_mark=”off” _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Douleurs” field_title=”Pain or specific symptoms:” required_mark=”off” _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Capacit\u00e9_physique” field_title=”Capacit\u00e9 physique actuelle : ” field_type=”select” select_options=”%91{%22value%22:%22Keep an eye on%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%22Average%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Good%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Excellent%22,%22checked%22:0,%22dragID%22:-1}%93″ _builder_version=”4.27.7″ _module_preset=”default” use_field_label=”on” use_field_placeholder=”on” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Titre_5″ fullwidth_field=”on” _builder_version=”4.27.7″ _module_preset=”default” use_field_html=”on” field_htmlcontent=”<\/p>\n

5 – Autorisation m\u00e9dicale et signature<\/span><\/h2>\n
\n

<\/h2>\n

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