Health Screening Form

For the purposes of obtaining a medical test and certificate(s) to participate in competitive and non-competitive sporting events. Please provide full and detailed information and answer all questions. On submitting this form, you will receive an email confirming the details you have entered. Please note that incomplete, incorrect submissions will be returned for re-submission.

 


Step 1 of 5

Your Details

Fields marked with a * are mandatory.

 

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if known eg. 118/78 mm Hg



Step 2 of 5

Your GP

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Your Previous Medical History

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Have you ever suffered any of from the following diseases?

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Your Current Medication

Fields marked with a * are mandatory.

 

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Hospital

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Step 3 of 5

Your Training

Fields marked with a * are mandatory.

 

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How many miles are you, cycling, running or swimming each week?
miles
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Don't know  minutes *
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cigarettes per day *
units per week *
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Step 4 of 5

Heart Disease

Fields marked with a * are mandatory.

 

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Step 5 of 5

Performance Enhancing Drugs

Fields marked with a * are mandatory.

 

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Medical Insurance

Fields marked with a * are mandatory.

 

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Your Events

Fields marked with a * are mandatory.

 

Please list the specific events you are entering over the next 12 months. For example Etape Du Tour, Marmotte. We will then provide signed stamped and dated entry forms or medical forms for specific events. You will also be provided with our generic medical certificate by default. We will provide signed, stamped and dated medical certificates and entry forms for 12 months of being approved.

Terms and Conditions

I understand that the personal information being submitted is securely protected under the data protection act of 1996. I also understand that this will only be used to assist in my cycling entrance event. I also state that all the data provided is present, correct and complete at the date it was submitted.

Disclaimer: Any Medical certificate is void if it is later discovered that any information has been falsely disclosed or deliberately with held. Please be advised that the medical certificate does not guarantee fitness for a cycling entrance event but represents the considered opinion of the doctor with all the information available at the time. It should be understood that dynamic studies of cardiac function such as cardiac echo or cardiopulmonary excercise testing, provide a much more accurate assessment of cardiovascular fitness, however this type of specialist testing is not required for the medical certification process unless clinically indicated.. Read full disclaimer.