Colchester United FC - Trialist Medical Questionnaire

In completing this medical form it will enable the medical team to support you adequately during your trial, for your own safety. Any information provided will be treated confidentially and maintained by the medical department only. If any areas need further discussion then consent will be sought from the player/parent/guardian.

Personal Information

Full Name *

Full name is required

Age Group *

Age group is required

Date of Birth *

Date of birth is required

Height (cms) *

Height is required

Weight (kgs) *

Weight is required

Contact Number *

Contact number is required

Emergency Contact Number *

Emergency contact is required

Medical History

1. Have you had a cardiac screening in the past 2 years? *

YES

Were there any abnormalities or advisories as a result of the screening?

YES

If yes, please specify the approximate dates and details:

2. Anyone in the family with a heart condition under the age of 50? *

YES

If yes, please specify:

3. Have you ever had a serious injury keeping you out of exercising for at least 4 weeks? *

YES

If yes, please specify:

4. Have you ever had a serious injury requiring hospitalisation, and/or surgery, or had a fractured bone? *

YES

If yes, please specify:

5. Do you have any reoccurring injuries?

Injury Type	Please Tick	Other Details
Muscle Strain
Growing Pain
Groin Pain
Back Pain
Knee Ligament
Ankle Ligament
Shoulder Instability

6. Have you had any serious head injuries/concussion in the past? *

YES

If yes, please specify:

7. If you answered yes to any of the above questions are there any medical limitations on your sporting activity? *

YES

If yes, please specify what:

8. Do you have any medical conditions such as asthma, diabetes, allergies etc? *

YES

Have you ever experienced shortness of breath during sports activity? *

YES

If yes, please specify what, giving details of any treatment/medication required:

9. Is there anything else, medically, that you think we should know? *

YES

If yes, please specify what:

Medical Department Policies

Please be aware that whilst trialling with Colchester United Football Club you must follow the medical department policies and procedures, which can be found on the online tool. To note: all injuries must be reported to the medical department directly and clearance to play/train must be obtained from the medical department after injury. Any trial deferrals due to injury will be discussed directly between the medical department and the FA. During your trial period the club is not liable for any illness or injuries incurred. The medical team will support you within their means for the duration of your time with Colchester United Football Club.

Date *

Date is required

Player/Parent/Guardian Signature *

(Parent/Guardian signature required if under 18 years)

Signature is required

Print Name *

Print name is required

Colchester United - Medical Disclaimer

For and on behalf of Colchester United Football Club.

I fully understand that Colchester United Football Club are not liable for any medical consultations, diagnostic scans or treatment that I may require as a result of any injuries that I sustain during any training sessions or any trial matches that I may be asked to play in.

Date *

Date is required

Player/Parent/Guardian Signature *

(& Parent/Guardian if the player is Under 18)

Signature is required

Print Name *

Print name is required

Witnessed on behalf of the Club

(For Club Use ONLY. Do not complete this section)

Witness Name

Any additional information or queries please contact the Medical Department:

Head of Academy Medicine

Oliver Reardon

Oliver.reardon@colchesterunited.net

Trialist Medical Questionnaire and Injury Disclaimer

Personal Information

Medical History

Medical Department Policies

Player/Parent/Guardian Signature *

Colchester United - Medical Disclaimer

Player/Parent/Guardian Signature *

Witnessed on behalf of the Club

Any additional information or queries please contact the Medical Department:

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