BDWF 2015
IN CONFIDENCE
NL
UK
HEALTH DECLARATION
For the safety of yourself and others in the Fellowship, it is necessary to know if you have ever suffered
from any of the following medical problems. Your answers will be kept in medical confidence.
Do not omit any section. Amplify any problem on a separate sheet of paper if necessary.
Our collection and retention of data is in accordance with the Data Protection legislation.
1. Personal information
Surname:
First name(s):
Address:
Title:
Date of birth:
Postcode:
Email:
Telephone 1 (mobile):
Telephone 2 (home):
Height:
Weight:
Emergency contact ……
Surname:
First name(s):
Telephone 1 (mobile):
Telephone2 (home):
2. European Health Insurance Card (EHIC)
Personal Identification Number:
Card Identification Number:
Expiry date:
3. Medical Problems
Y/N? Details
Do you have any mental and/ or
physical problems at the
present time?
Have you had any major illness
or operative treatment in the
last 5 years?
Are you on any prescribed
medication or over the counter
medication at the present time?
Have you ever had a problem
with drugs or alcohol?
Have you ever been removed
from an activity for health
reasons?
Are you pregnant? If so, please
provide estimated date of
delivery.
Have you been immunised
against Hepatitis B?
Have you been immunised
against Tetanus?
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Issue 2015 / 1 - October 2014
BDWF 2015
IN CONFIDENCE
NL
HEALTH DECLARATION
4. Doctor consultations
Please indicate whether you have consulted a doctor about any of the following problems.
If your answer is Yes to any of the statements below then you MUST provide brief details.
Y/N? Details
Heart disease, Angina?
Asthma, Bronchitis or wheezing,
COPD, chest infections?
Any loss of consciousness,
blackout, seizures or epilepsy
(this includes any history of
fainting episodes)?
Severe headaches or migraines
requiring medication?
High or low blood pressure?
Back, neck or any joint
problems?
Brain injury or stroke?
Indigestion or peptic ulcer
Diabetes?
If yes, please state, type 1 or
type 2 and if you require
insulin?
Hearing problems?
Visual problems?
Allergies?
Please state type and if you
carry an injector pen?
Stress, anxiety, depression or
mental conditions?
Rupture or hernia?
Any other disability?
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Issue 2015 / 1 - October 2014
UK
BDWF 2015
NL
IN CONFIDENCE
UK
HEALTH DECLARATION
5. Other
Y/N? Details
Do you have any dietary
requirements?
Do you have any diet
restrictions or special food
needs?
Do you have a religion?
Is there any further information
you feel we need to know?
6. Declaration and Signature
I declare that the information I have provided on this form is correct and that I am medically fit to
participate in the Nijmegen Vierdaagse. I undertake to inform the BDWF First Aid Coordinator of
any alteration in my state of fitness whether temporary or permanent. I understand that false or
misleading information could lead to my removal from participating in the Nijmegen Vierdaagse.
Signed:
Date:
For members under the age of 18 …….
Name of Parent/ Guardian/ Carer:
Surname:
First name(s):
Signed:
Thank you for completing this form.
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Issue 2015 / 1 - October 2014
Date: