Deben Rowing Club Medical Questionnaire

Name:
Date of Birth:
DRC membership No:

Please answer all the following questions.

If you answer yes to any questions please give details in the space at the end.
As with any sport on open water there are potential dangers and the club has a responsibility to ensure
you are safe to row.
Please be assured that most conditions do not exclude rowing but the club needs to be aware so that
appropriate support and insurance cover can be arranged.
All answers will be treated with strictest confidence but if a condition is disclosed, we would discuss with
the individual exactly who needs to be made aware.
Forewarned is forearmed if there is a medical problem on the water.

Vision YES NO

Are you unable to read a standard car number plate at 20 metres? [ ] [ ]

If corrective lenses are required to achieve this, are they:
glasses [ ] contact lenses [ ] both together [ ]
Are you unable to judge distances normally? [ ] [ ]
Do you ever have double vision? [ ] [ ]
Are you colour blind? [ ] [ ]
Do you have any other eye condition? [ ] [ ]

Nervous System

Have you ever had any form of seizure? [ ] [ ]

Have you blacked out or lost consciousness in the last 5 years? [ ] [ ]
Have you ever had ANY of the following?
Stroke, TIA, Subarachnoid haemorrhage [ ] [ ]
Sudden disabling dizziness in the last year [ ] [ ]
Parkinsons, MS, Motor Neurone Disease [ ] [ ]
Brain tumour, brain injury, brain surgery [ ] [ ]
Muscle weakness [ ] [ ]

Psychiatric Illness

Have you had ANY of the following within the last 3 years?
Psychosis, mania [bipolar affective disorder], severe depression [ ] [ ]
OCD, eating disorder, self-harm [ ] [ ]
ADHD, autistic spectrum disorder, conduct disorder [ ] [ ]
Dementia or cognitive impairment [ ] [ ]
Alcohol misuse or dependence [ ] [ ]
Drug misuse or dependence [ ] [ ]
Diabetes Mellitus

Do you have Diabetes Mellitus? [ ] [ ]

Cardiac YES NO

Have you ever had angina or a myocardial infarction? [ ] [ ]

Have you undergone coronary angioplasty or bypass surgery? [ ] [ ]
Have you ever had a cardiac arrhythmia [persistent palpitations] [ ] [ ]
Have you ever had ANY of the following ?
Peripheral arterial disease [ ] [ ]
Intermittent claudication [calf pain on exertion] [ ] [ ]
Aortic aneurism or dissection [ ] [ ]
Marfans disease [ ] [ ]
Congenital heart disease [ ] [ ]
Heart valve disease [ ] [ ]
Heart failure [ ] [ ]
Cardiomyopathy [ ] [ ]
Have you ever been found to have high blood pressure? [ ] [ ]

Respiratory

Do you have asthma? [ ] [ ]

Do you have any other ongoing lung disorder? [ ] [ ]
Do you get wheezy [whistling in the chest on breathing in] with [ ] [ ]
exertion or on exposure to cold air, dusts or pollens?
Do you become breathless or get chest pain when you climb [ ] [ ]
3 flights of stairs at a reasonable pace?

General

Do you have ongoing low back pain? [ ] [ ]

Do you have any other chronic muscle or joint problems? [ ] [ ]
Do you suffer from unexplained fatigue? [ ] [ ]
Do you have a marked hearing loss? [ ] [ ]
Have you ever had liver disease or renal failure? [ ] [ ]
Do you take any medicines that cause drowsiness or fatigue? [ ] [ ]
Do you have any allergies [i.e. medicines, foods, plants, plasters, etc]? [ ] [ ]
Do you have any other condition that could affect safe rowing? [ ] [ ]

Further information
Signature Date
[Parent / guardian for juniors]