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Medical ParQ
Please complete the form below so we can gather vital information for our Physio Staff at DENG Camp UK [2019]
*
indicates required
Full name
Email Address
*
1. Allergic to any medication?
*
No
Yes
If yes, list
2. Prescribed medication?
*
No
Yes
If yes, list and give reason
3. Epileptic seizure?
*
No
Yes
4. Treated for diabetes?
*
No
Yes
5. High blood pressure?
*
No
Yes
6. Asthma?
*
No
Yes
If yes, list any medication
7. Head injury
*
No
Yes
If so, describe and give date(s)
8. Neck injury
*
No
Yes
If so, list type of injury and dates
9. Glasses or contacts?
*
No
Yes
10. Broken bone?
*
No
Yes
If so, give details, right or left and dates
11. Back Pain
*
No
Yes
If so, which one applies
Seldom
Occasionally
Frequently With Vigorous Exercise
With Heavy Lifting
12. Knee cartilage?
*
No
Yes
If so, specify left or right and date(s)
13. Knee Surgery?
*
No
Yes
If so, specify left or right and date(s)
14. Ankle sprain?
*
No
Yes
15. Do you have a pin, screw, or plate in body?
*
No
Yes
If so, specify where in your body and date(s)
16. Other conditions?
*
No
Yes
If so, specifiy and give details
Consent for Physiotherapy Treatment
Yes
No