Application health screening - NTU Sports Analysis and Performance

First Name*

Last Name*

Email address*

Date of birth*

Please complete this brief questionnaire to confirm fitness to participate:

1. At present, do you have any health problem for which you are:

(a) on medication, prescribed or otherwise*

Yes
No

(b) attending your general practitioner*

Yes
No

(c) on a hospital waiting list*

Yes
No

2. In the past two years, have you had any illness which has required you to consult your GP?*

Yes
No

Do you wish to confirm the problem was/is short-lived, insignificant or well controlled?*

Yes
No

Please provide a description of the circumstances here:*

3. In the past two years, have you had any illness which require you to:

(a) attend a hospital outpatient department*

Yes
No

(b) be admitted to hospital*

Yes
No

4. Have you ever had any of the following?

(a) Convulsions/epilepsy*

Yes
No

(b) Asthma*

Yes
No

(c) Eczema*

Yes
No

(d) Diabetes*

Yes
No

(e) A blood disorder*

Yes
No

(f) Head injury*

Yes
No

(g) Digestive problems*

Yes
No

(h) Heart problems*

Yes
No

(i) Problems with bones or joints*

Yes
No

(j) Disturbance of balance/coordination*

Yes
No

(k) Numbness in hands or feet*

Yes
No

(l) Disturbance of vision*

Yes
No

(m) Ear/hearing problems*

Yes
No

(n) Thyroid problems*

Yes
No

(o) Kidney or liver problems*

Yes
No

(p) Allergy to nuts, alcohol etc.*

Yes
No

(q) Any problems affecting your nose e.g. recurrent nose bleeds*

Yes
No

(r) Any nasal fracture or deviated nasal septum*

Yes
No

5. Has any, otherwise healthy, member of your family under the age of 50 died suddenly during or soon after exercise?*

Yes
No

6. Are there any reasons why blood sampling may be difficult?*

Yes
No

7. Have you had a blood sample taken previously?*

Yes
No

8. Have you had a cold, flu or any flu like symptoms in the last month?*

Yes
No

9. Are you pregnant, trying to become pregnant or breastfeeding?*

Yes
No
N/A

If you have been asked to upload more information, please do this using the option below:

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Email

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Continue your application

Thank you for completing the PAR-Q form, prior to being accepted on to the programme please complete this brief questionnaire to confirm fitness to participate:

Please complete this brief questionnaire to confirm fitness to participate: