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MEDICAL QUESTIONAIRE

To be completed by all participants before commencing any activity. This information will be held in confidence by instructors, staff and teaching staff until such time as the information is required
Name:

Age:

Sex:

Address:

Name, phone number & Address of next of Kin:

Name, phone number & address of Doctor:

Can you swim (approx. how far):

Do you suffer from:
A Bad Back
Asthma
Diabetes
High Blood pressure
Epilepsy
Migraine

Are you currently on any medication:

Do you have any allergies (inc. Penicillin, Asprin etc.):

Any other information you feel we require:

.........
Thank you for taking the time to complete this form. Should you have any queries regarding the above please do not hesitate to contact us.

 

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