RRUFC Physio Medical Information & Consent FormFirst NameLast NameAddressAddress Line 1Address Line 2TownPostcodeEmailDate of BirthNext of Kin & Contact NumberMedical DetailsAny problems will be discussed with your physiotherapist in more depthDo you have any heart problems?– Select –YesNoDo you have a cardiac pacemaker? – Select –YesNoDo you have high/low blood pressure?– Select –YesNoDo you have any breathing problems (e.g. asthma/bronchitis)?– Select –YesNoHave you ever taken steroids?– Select –YesNoDo you have diabetes?– Select –YesNoDo you suffer from epilepsy or seizures?– Select –YesNoHave you ever had anticoagulant therapy (i.e. Warfarin/Aspirin)?– Select –YesNoHave you ever been diagnosed with cancer?– Select –YesNoAre you pregnant? (LADIES ONLY!)– Select –YesNoAre you taking any regular medication? If so, please list:Have you any allergies? If so, please list:CONFIRMATIONIF AT ANY POINT YOU DEVELOP ANY ILLNESS IT IS YOUR RESPONSIBILITY TO TELL THE CLUB MEDICAL STAFF IMMEDIATELY. PLEASE READ CAREFULLY ON SIGNING THIS FORM I HEREBY CONSENT TO RECEIVING PHYSIOTHERAPY/ MEDICAL ASSESSMENT / TREATMENT.This may include: Initial assessments, Treatment (Hands on Techniques , Electrotherapy, Massage), Tests (X-ray, scan, hospital referral) THIS LIST IS NOT EXHAUSTIVE AND ANY INTERVENTION WILL BE THE DECISION OF THE HEALTHCARE PROVIDER EMPLOYED BY RRUFC I confirm that all of the information I have given on this form is correct to the best of my knowledgeSubmit Form
