BSC Health Questionnaire


In the interest of your player's safety please complete the following health questionnaire in confidence.



Player's Name	:
Team		:
Address		:
Tel Number	(H)                                        
		(A/H)                                         
		(M)
Next of Kin	:
Name		:
Address		:
Tel Number	(H)                                         
		(A/H)                                         
		(M)




Do you suffer from any allergies e.g. bandaids, massage oil,  or antibiotics?






Are you currently taking any long-term medication such as Ventolin, Insulin, cortisone?






Do you suffer from any long-term conditions such as epilepsy, diabetes, asthma, heart murmur?






Have you had any surgery in the past?






Do you have any family history of serious disease? 






Is there any other issue you would like your coach to be aware of regarding your health?





PLEASE RETURN THIS FORM TO ME ASAP.