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.

  • About you
  • Past Medical History
  • General Health
  • Injury History
  • Drug History
  • Social History
  • Complete
Required field

About you

I confirm that I am making this appointment for injury support, or a rehabilitation check-in, and not a general advice session.
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
Your physio allocation was detailed on the email that confirmed your inclusion on the high-performance programme, received by your Captain and President. If they are unsure, please email [email protected], but this will slow down the process of you being seen!

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:
Do you have any Heart problems. If yes, please explain further.
Do you have a diagnosis of inflammatory arthritis. If yes, please explain further.
Do you suffer from Epilepsy? If yes, please explain further.
Do you suffer currently or in the past with Asthma? If yes, please explain further.
Do you have Diabetes? If yes, please explain further.
Have you ever taken any steroid medications? If yes, please explain further.
Do you have a current problem with or history of Cancer?
Have you had any previous surgeries or operations. If yes, please explain further.
Have you ever been in hospital for a prolonged period of time? Please explain further if yes…

General Health

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

Injury History

Drug History

Social History