Sports Medical Consultation; Medical Certificates

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Name* This field is required.

First Name

Last Name

2

Date of Birth* This field is required.

Date

3

Age* This field is required.

Please note, we recommend athletes over the age of 60 undertake in-personal sports medical assessments.

4

Sex* This field is required.

Female

Male

Prefer not to say

5

Email * This field is required.(where the certificate will be delivered)

6

Phone* This field is required.

This number will be used to inform you when your certificate is ready, and may be used by the clinical team to contact you if any further information is required.

7

Address

Street Address

Street Address Line 2

City

County

Post Code

Country

8

Do you plan to take part in a competitive sports event in Italy?* This field is required.

YESNO

9

If your sporting event is in Italy, and you require an event-specific form to be signed, you will need to upload the results for the following tests undertaken within the last 12 months: Resting ECG and Stress ECG, Spirometry (a lung function test), urinalysis. Do you have these results and would you like to continue?If you do not need an event-specific form signed and would simply like a generic sports medical certificate, then we can proceed without the additional tests. You can also click the save icon below to save your progress and return to this form later.

YESNO

10

Please describe any health related issues you have consulted your GP about in the the last 3 years:

11

Have you been admitted to hospital for any reason in the past 3 years?* This field is required.

YESNO

12

Please describe your hospital admission(s)

13

Do you take any medication (whether prescribed or purchased over-the-counter)?* This field is required.

YESNO

14

Please list all regular medication you take:

15

Are you pregnant or have you given birth in the last 3 months?* This field is required.

YESNO

16

Please provide details regarding your pregnancy

17

BMI (please enter height and weight)* This field is required.Click the conversion icon below to switch between Imperial and Metric units

18

Blood Pressure* This field is required.

19

Heart Rate at restIf you do not have a heart rate monitor, sit quietly for ten minutes, then place 2 fingers on your pulse and count the beats for 15 seconds. Multiply that number by 4.

20

Do you suffer from COPD?* This field is required.

YESNO

21

Do you suffer from Asthma?* This field is required.

YESNO

22

Please provide further details of your Asthma:* This field is required.

23

When was your last exacerbation and how many exacerbations do you tend to suffer from per year?* This field is required.

24

How often do you use your reliever inhaler?* This field is required.

25

Do you suffer from a wheeze when you exercise or are exposed to cold air?* This field is required.

YESNO

26

Have you been diagnosed with High Blood Pressure?* This field is required.

YESNO

27

How is your blood pressure controlled?eg. through diet or medication? Which medication?

28

What is your highest blood pressure within the last 3 months?

29

Do you suffer from Epilepsy?* This field is required.

YESNO

30

Have you ever had Rheumatic Fever?* This field is required.

YESNO

31

Have you ever suffered a Stroke?* This field is required.

YESNO

32

Do you suffer from Diabetes or Pre-diabetes (high blood sugar)?* This field is required.

YESNO

33

Do you suffer from Cardiac Arrythmias or Palpitations (irregular heart beats)* This field is required.

YESNO

34

Do you suffer from Valvular Disease? (any problem with your heart valves)* This field is required.

YESNO

35

Do you suffer from Marfans or connective tissue disease* This field is required.

YESNO

36

Have you ever suffered a Heart Attack or Heart Failure?* This field is required.

YESNO

37

Do you have high cholesterol?

YESNO

38

Do you suffer from Bleeding disorders? eg. Haemophilia* This field is required.

YESNO

39

Have you ever experienced Water Intoxication?* This field is required.

YESNO

40

Have you ever suffered from Heat Stroke?* This field is required.

YESNO

41

Any other chronic disease?* This field is required.

YESNO

42

Please provide further details

43

Do you have history of any heart disease or heart surgery?* This field is required.

YESNO

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