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
  • Data Collection
  • 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

Data Collection

Before we proceed with your appointment, I want to inform you about an important aspect of how we document our consultations. I utilise a note taking tool called Heidi to accurately and efficiently capture the details of our discussions and the outcomes of our appointments. Heidi ensures that we can focus more on our conversation and less on manual note taking, enhancing the quality of care you receive.


Your consent is crucial for us to use this technology. Please understand that your information will be handled with the utmost care, and Heidi’s use is aimed solely at improving your healthcare experience.

Purpose of Heidi

Heidi is used to assist with documenting your consultation, capturing only what is necessary for accurate medical records.

Heidi supports but does not replace your clinician’s professional judgment. All medical decisions are made solely by your clinician.

Your Data

Your data is processed and stored in your jurisdiction and in accordance with
applicable privacy laws.

None of your data is used for secondary purposes.

Data undergoes a rigorous de-identification
 process to remove personal identifiers.

Data is handled securely, with encryption and regular audits to ensure compliance.

Your rights
You can choose to opt-out of the use of Heidi during your consultation

By signing this consent form, you acknowledge that:

1. You have been informed about the use of Heidi and its purpose.

2. You understand how your information will be handled, stored, and protected.

3. You agree to allow your clinician to use Heidi to assist with documenting your consultation.

4. You understand that you can withdraw your consent at any time without affecting the quality of care you receive.

Sign above