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Player profile form Personal details Name Address Telephone Mobile Email Date of birth Emergency contact Relationship to player Medical history Do you have any medical conditions disabilities or allergies If the answer is yes please list each condition disability or allergy and any medication you take for it. Condition / disability e.g. asthma diabetes epilepsy anaemia haemophilia viral illness etc Allergy e.g. bee stings etc Medication e.g. tablets inhalers Frequency e.g. twice daily only with creams etc - give drug names symptoms etc Dose / frequency History of injury list any injuries when they happened and who treated you Injury e.g. concussion When e.g. Sept 2007 Rugby Ready / Pre-participation / Player profile Treatment received Who treated you Current status of injury e.g. doctor fully recovered or not Health and fitness assessment In which other sports / physical activities are you involved How many hours per week do you train Have you played Rugby before If yes where and for how many seasons Height Cardiac questionnaire please tick each box that applies to you Fainting Palpitations Dizzy turns Chest pain or tightness Breathlessness or more easily tired than team- Sudden death in your immediate family of anyone mates under 50 History of high blood pressure Smoking how many per day Diabetes Signatures Date of profile completion Player s signature or guardian if under 18 Profiler s signature Follow-up date if applicable. Player profile form Personal details Name Address Telephone Mobile Email Date of birth Emergency contact Relationship to player Medical history Do you have any medical conditions disabilities or allergies If the answer is yes please list each condition disability or allergy and any medication you take for it. Condition / disability e*g* asthma diabetes epilepsy anaemia haemophilia viral illness etc Allergy e*g* bee stings etc Medication e*g* tablets inhalers Frequency e*g* twice daily only with creams etc - give drug names symptoms etc Dose / frequency History of injury list any injuries when they happened and who treated you Injury e*g* concussion When e*g* Sept 2007 Rugby Ready / Pre-participation / Player profile Treatment received Who treated you Current status of injury e*g* doctor fully recovered or not Health and fitness assessment In which other sports / physical activities are you involved How many hours per week do you train Have you played Rugby before If yes where and for how many seasons Height Cardiac questionnaire please tick each box that applies to you Fainting Palpitations Dizzy turns Chest pain or tightness Breathlessness or more easily tired than team- Sudden death in your immediate family of anyone mates under 50 History of high blood pressure Smoking how many per day Diabetes Signatures Date of profile completion Player s signature or guardian if under 18 Profiler s signature Follow-up date if applicable. .

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