Sports Medical Questionnaire
Complete the form to receive your sports medical certificate from £55.
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START
Title
*
Name
*
First Name
Last Name
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Date of Birth
*
-
Day
-
Month
Year
Date
Age
Sex
*
Female
Male
Prefer not to say
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Email (where the certificate will be delivered)
*
Phone
*
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Please describe any health related issues you have consulted your GP about in the the last 3 years:
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Have you been admitted to hospital for any reason in the past 3 years?
Yes
No
Please describe your hospital admission(s)
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Do you take any medication (whether prescribed or purchased over-the-counter)?
Yes
No
Please list all regular medication you take:
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Are you pregnant or breastfeeding?
Yes
No
Please provide details regarding your pregnancy
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Height
Weight
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Blood Pressure
*
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Medical History
Have you ever suffered from any of the following conditions?
High blood pressure
Yes
No
Heart Attack
Yes
No
Cardiac Arrythmias or Palpitations (irregular heartbeats)
Yes
No
Asthma or COPD
Yes
No
Stroke
Yes
No
Rheumatic Fever
Yes
No
Diabetes
Yes
No
Epilepsy
Yes
No
Thyroid Disease
Yes
No
Bleeding disorders eg. Haemophilia
Yes
No
Water intoxication
Yes
No
Heat Stroke
Yes
No
Any other Chronic disease
Yes
No
If yes, please describe
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Heart Disease Risk
These questions specifically screen for likelihood of heart disease
Do you have history of any heart disease?
*
Yes
No
If yes, please supply full details
*
Is there any family history of sudden cardiac death in close relatives (brothers, sisters, parents) under 50 years of age?
*
Yes
No
If yes, please supply full details
*
Do you suffer from or have you suffered with chest pains and/or tightness when exercising?
*
Yes
No
If yes, please supply full details
*
Do you suffer from or have you suffered with excessive breathlessness or wheeze when exercising?
*
Yes
No
If yes, please supply full details
*
Do you suffer from or have you suffered with dizziness when exercising? *
*
Yes
No
If yes, please supply full details
*
Have you ever suffered from dizziness when NOT exercising? *
*
Yes
No
If yes, please supply full details
*
Do you suffer from or have you suffered from palpitations (a very fast or skipped heart beat) when exercising? *
*
Yes
No
If yes, please supply full details
*
Have you ever collapsed or lost consciousness whilst at rest or exercising? *
*
Yes
No
If yes, please supply full details
*
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Your Training
Have you been training and plan to train in an adequate fashion to attempt a sporting event? *
*
Yes
No
How far are you cycling, running or swimming each week?
Cycling
Running
Swimming
How long do you push your heart rate to 70% of its maximum for?
minutes
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Have you completed any entrance events before?
*
Yes
No
Have you ever fainted?
*
Yes
No
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How much do you smoke?
*
cigarettes per day
How much do you drink?
*
units per week
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Are there any other medical issues that we need to be aware of?
Yes
No
Please provide details
*
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Have you ever taken performance enhancing drugs?
Yes
No
Have you ever taken steroids to improve sporting performance?
Yes
No
Have you ever been refused medical insurance?
Yes
No
Please provide details to any questions answered yes above
*
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Your Events
Please list the events you are entering over the next 12 months. You will be provided with our generic medical certificate if you have not requested a specific format. If any of your events require a specific certificate template or form, please indicate in this section and upload the required template in the next page. We will issue a signed, stamped and dated medical certificate valid for 12 months from approval.
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Upload any certificate templates or entry forms here
Browse Files
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Please attach a copy of your passport or driver's licence as proof of identification.
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Select your service
*
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( X )
Standard (within 2-4 working days)
£
55.00
Express (within 24hrs)
£
59.00
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Terms
Upon submitting your information, you acknowledge our Terms and Privacy Policy and consent to the following:I understand that the personal information being submitted is securely protected under GDPR. I consent to having this website store my submitted information so they can respond to my inquiry.I understand that this will only be used to assist in my entrance event. I also state that all the data provided is present, correct and complete at the date it was submitted.I understand the questions in the questionnaire and answered them honestly.The requested letter is solely for the individual with the provided name and details.Medical Cert's online sports medical certificate is not a replacement for a specialist sports medicine consultation.Medical Cert is not your primary doctor or sports physician, and the doctor issuing your certificate may be unable to access your NHS or regular GP medical records.Medical Cert is unable to process refunds once a letter has been written and sent to you.
*
I agree to the Terms & Conditions
Disclaimer
Any medical certificate is void if it is later discovered that any information has been falsely disclosed or deliberately withheld. Please be advised that the medical certificate does not guarantee fitness for an 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 exercise testing provide a much more accurate assessment of cardiovascular fitness, however this type of specialist testing is not usually required for the medical certification process unless clinically indicated.
*
I agree to the Disclaimer
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