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INA ENGLAND – MEDICAL QUESTIONNAIRE AND CONSENT FORMS In line with our health and safety policy, please provide details of any medical information you feel we should be aware of. These pages will be kept confidentially by the Welfare Secretary, but key information may be stored in kit bags in case of emergency on match days. (Please see consent request on page 2). Please note that it is your responsibility to look after your own well-being and safety when taking part in activities with the INA England.
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q) For most people physical activity should not pose any problem or hazard. The PAR-Q is designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Common sense is the best guide in answering these few questions. Please read them carefully and check the correct answer opposite the question if it applies to you. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse with exercise? Do you have high blood pressure? Do you have low blood pressure? Do you have Diabetes Mellitus or any other metabolic disease? Has your doctor ever said you have raised cholesterol (serum level above 6.2mmol/L)? Has your doctor ever said that you have a heart condition and you should only do physical activity recommended by a doctor? Have you ever felt pain in your chest when you do physical exercise? Is your doctor currently prescribing you drugs or medication? Have you ever suffered from unusual shortness of breath at rest or with mild exertion? Is there any history of coronary heart disease in your family? Do you often feel faint, have spells of severe dizziness or have lost consciousness? Do you currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women)? Do you currently smoke? Do you NOT currently exercise on a regular basis (at least 3 times a week) and/or work in a job that is physically demanding? Are you, or is there any possibility that you might be pregnant? Do you know of any other reason why you should not participate in a program of physical activity?
YES
NO
YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES
NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO
If you answered: Yes to one or more questions: If you have not recently done so, consult with your doctor by telephone or in person before increasing your physical activity and/or taking a fitness appraisal. Tell your doctor what questions you answered ‘yes’ to on the PAR-Q or present your PAR-Q copy. After medical evaluation, seek advice from your doctor as to your suitability for: • •
Unrestricted physical activity starting off easily and progressing gradually, and Restricted or supervised activity to meet your specific needs, at least on an initial basis
No to all questions: If you answered the PAR-Q accurately, you have reasonable assurance of your present suitability for: • •
A graduated exercise programme Trialling for the INA England.
"I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction." Name: Date: Signature: Date: Signature of Parent of Guardian (if applicable): Date: Witness: Date:
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MEDICAL HISTORY TITLE
FORENAME
DOB
M/F
SURNAME HEIGHT (ft)
DOCTOR / GP
WEIGHT (kg) CONSULTANT / SPECIALIST
CLINIC ADDRESS
ADDRESS
ILLNESS Please list all illnesses, diseases or conditions you have suffered from. I.e. Cancer, diabetes, TB, rheumatic fever, pneumonia, etc. (You may include colds, cough & flu)
ACCIDENTS Please list any accidents, fractures, injuries you have had including car, motorbike or of you have suffered and significant physical trauma to your body.
OPERATIONS/ PROCEDURES Please list any surgery, investigations, tests, scans or X-Rays.
DO YOU SUFFER FROM ANY CONDITIONS RELATING TO YOUR (1) (2)
Heart or Lungs, i.e. blood pressure, breathing difficulties, strokes, heart attacks, TIA etc. Bowels or Bladder i.e. irritable bowel, diarrhoea, constipation, ulcer, prostrate, reflux, urinary infections, thrush, cystitis, difficulties going to the toilet.
NEUROLOGY Have you suffered from blackouts, nausea, dizziness, fainting, double vision, tingling, numbness, epilepsy etc.
DRUGS/MEDICATION Please list any drugs/medication that you are taking or recently have been taking.
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MEDICAL HISTORY (cont.) ALLERGIES List any food, medicine or substances/products you are allergic to or conditions i.e. hay-fever, Eczema, Asthma etc.
Have you ever had any abnormal bleeding after dental extractions, surgery or injury?
Is there an area of your medical history that we have not yet asked you about or any further comments you wish to make?
SIGNATURE I am in good health and capable of taking part in physical activity with INA England
Y/N
I have checked the medical details provided above and consent that, in the event of illness/accident, any necessary treatment can be administered to me. This may include the use of anaesthetics, or basic first aid or CPR administered by a member of the public.
Y/N
I consent to my medical information, as provided above, being stored in kit bags, alongside emergency contact details, in case of need on match days.
Y/N
I understand that while coaches and personnel of INA England will take every precaution to ensure that accidents do not happen, they cannot necessarily be held responsible for any loss, damage, injury or death that I suffer and that the INA England accepts no responsibility for any personal harm that may occur.
Y/N
I am aware that INA-authorised photographers may take stills or video during activity, to be used for publicity in local press, on the INA England website or in INA England authorised publicity, and agree that I can feature in such photos.
Y/N
Name
Signature
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Date