Hampstead and Westminster HC Player Medical Screening and Injury declaration 2020/21
Contact Details
Name*
First Name Last Name
Squad*
Birth Date*
Day Month Year
Age*
Mobile Phone*
Area Code Phone Number
Home Phone
Area Code Phone Number
E-mail*

Confirmation Email
Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
In Case of Emergency/Next of Kin
Name*
First Name Last Name
Contact number*
Area Code Phone Number
Alternative contact number
Area Code Phone Number
Health & Medical Information
Do you suffer from any general health problems? eg: Asthma, Diabetes, Seizures*
Yes No
If Yes, please give full details
Have you been diagnosed with a serious illness/condition in the past? eg: Cancer, Heart conditions*
Yes No
If Yes, please give full details
Are you taking any medication at present?*
Yes No TUE (Therapeutic Use Exemption)- certificate required
If Yes, please give full details
Do you have any allergies? eg: medication, latex, plasters, strapping, food*
Yes No
If Yes, please give full details
Are you currently injured?*
Yes No
If Yes, please give full details
Have you had any serious injuries this season that caused you to miss training/playing for more than 2 weeks?*
Yes No
If Yes, please give full details
Have you had any major injuries in your career that required you to miss training/playing for more than 4 weeks?*
Yes No
If Yes, please give full details
Have you suffered from a head injury/concussion in the past 4 weeks?*
Yes No
If Yes, please give full details
Please upload any relevant medical reports
Consent to Assessment and Treatment
At times the medical staff will have to liaise with the referee, coaching staff, management staff and attending medical practitioners regarding injuries. However, any of the personal medical details on this form will only be given with your permission. The details will be kept confidential within the medical team.
At sporting events, it is not always possible to provide privacy when being assessed and/or treated. Should you and your practitioner decide privacy is needed or wanted then a suitable private area will be provided if possible.
This form is your decleration of consent to assessment and treatment.
Full Name*
First Name Last Name
*
Day Month Year
I (named above) consent to be examined on the field of play and/or in a designated area for assessment should an injury occur. I consent to receive manual therapy 'on pitch' and in a designated area. I consent to receive care following an initial 'on pitch' assessment.*
Tick to confirm consent
Should be Empty: