High Performance Programme and Elite Athlete Physio Access

This form is to be completed alongside your request to see Wayne (our High Performance Physio). To complete this form, you must be a listed member of a High-Performance Squad or an Elite Athlete.

You only need to complete this form once, but please ensure that your Captain is aware of the number of sessions that you have had with Wayne. Elite Athletes do not need to follow this step.

This process will enable us to keep track of who is using the service, and which Clubs are engaging best.

Please note that all submissions of this form will only be viewed by the High Performance Programme staff lead and the High Performance Programme contracted Physiotherapist. All information will be stored in line with GDPR regulations.

Current About you
Past Medical History
General Health
Injury History
Drug History
Social History
Complete

Required field

About you

First

Last

UCL Email Address

Date of Birth

I confirm that I am making this appointment for injury support, or a rehabilitation check-in, and not a general advice session.

Yes

The High Performance Physio support operates as an injury clinic, and unfortunately we cannot offer general check-ins for speculative advice.

How severely is your injury impacting your performance?

I am unable to play

Marginally impacting my ability to play

Are you an Elite Athlete or member of a High Performance Team?

How many sessions have you had with the High Performance Physio since the start of this academic year?

Past Medical History

Please comment if any immediate family members have these issues too.

Do you have any Thyroid problems. If yes, please explain further:

Yes

Do you have any Heart problems. If yes, please explain further.

Yes

Do you have a diagnosis of inflammatory arthritis. If yes, please explain further.

Yes

Do you suffer from Epilepsy? If yes, please explain further.

Yes

Do you suffer currently or in the past with Asthma? If yes, please explain further.

Yes

Do you have Diabetes? If yes, please explain further.

Yes

Have you ever taken any steroid medications? If yes, please explain further.

Yes

Do you have a current problem with or history of Cancer?

Yes

Have you had any previous surgeries or operations. If yes, please explain further.

Yes

Have you ever been in hospital for a prolonged period of time? Please explain further if yes…

Yes

Do you have any other medical conditions I would need to be aware of?

Do you have any other medical conditions I would need to be aware of?
Do you have any other medical conditions I would need to be aware of?

General Health

How would you describe your general health? (excellent to poor)?

Poor

Excellent

Do you smoke? If so how many per week?

Do you drink Alcohol. If so how many units per week on average?

Injury History

Please list all significant previous musculoskeletal injuries you have had, and approximately when they were diagnosed?

Please list all significant previous musculoskeletal injuries you have had, and approximately when they were diagnosed?
Please list all significant previous musculoskeletal injuries you have had, and approximately when they were diagnosed?

Drug History

Do you take any regular medication? If yes, please explain including dosage.

Do you take any regular medication? If yes, please explain including dosage.
Do you take any regular medication? If yes, please explain including dosage.

Do you have any allergies? If yes please explain further.