1on1 Masterclass Medical Assessment – Melbourne Victory Academy

Complete this form to give us an overall view of your medical history.

In addition to this Medical Assessment we will also require you to complete our online medical screening assessment.

You can do this yourself by following our online Medical screening tutorial below;

To complete your Online Medical Screening CLICK HERE

To view your online Medical Screening Tutorial CLICK HERE

Player Name (required)

Player Age (required)

Emergency Contact Name (required)

Emergency Contact Number (required)

Email Address (required)

Do you suffer from any medical conditions e.g asthma, diabetes, epilepsy, high blood pressure? (required - If none write N/A)

If so, do you take any medications e.g. inhalers, insulin, epipen? Do you have an ASASA-sanctioned TUE in place for these medications?(required - If none write N/A)

Do you have any allergies? (required - If none write N/A)

Do you take any supplements? If yes what do you take and how much do you take? (required - If none write N/A)

Does your family have any history of cardiac conditions? (required - If none write N/A)

Have you previously had any soft tissue injuries (muscle or tendon)? (required - If none write N/A)

Have you had any previous joint or ligament injuries? Please list each soft tissue injury you have sustained, approximate date and the number of weeks missed (required - If none write N/A)

Do you have a family history of ACL injury? (required - If none write N/A)

Have you had any other major injuries (e.g. fracture)? (required - If none write N/A)

Have you suffered a concussion? If so, what investigations were performed? (required - If none write N/A)

Have you had any previous surgeries? (required - If none write N/A)

Have you completed our Medical Assessment Online Screening Procedure? (You will have to complete this assessment before taking part in the program)
YESNO