Health Questionnaire

This PRE-TRAINING HEALTH SCREEN is for use at KaOM/GSA training.

Please complete this confidential questionnaire designed to help us, and you, identify any areas of your health which may influence your ability to safely take part in GSA physical intervention/restraint and breakaway physical skills training. This training is designed to be accessed by people of a wide range of ages, weight, co-ordination and levels of physical fitness. It is designed to ensure that you will be able to carry out the day to day training requirements more safely. If you are concerned about any aspect of your health in the context of physical skills training, we recommend that you seek advice from your GP or Occupational Health Department prior to attending physical skills training. Please discuss any concerns you may have with your health on completion of this form with the course tutor prior to the course commencement or on the day of training prior to the course.
Failure to declare injuries or pre-course medical conditions places the responsibility on the participant and not the training faculty.

Pre-Training Health Questionnaire

We treat your information with confidentiality. Your records will be kept for a maximum of 4 years only for training needs in line with GDPR.

All questions must be answered.

You will be expected to fully participate with training. Please dress sensibly in sports clothing. You will be assessed at the end of the training both in practical and theory. Tutors will support you to be safe for yourself, colleagues and patients/clients/service users.

Name

Date of Birth

Email

Contact number

*The physical nature of PMVA does not permit us to train anyone who is pregnant. KaOM/GSA has health questionnaires to be completed before physical training.

1. Are you, or do you think you might be, pregnant? If you think you may be pregnant you should not participate in a physical skills course – please consult Occupational Health

2. Are you mentally and physically fit to go down to your knees and floor holding someone?

3. Do you have any special needs that may affect your learning or assessment?

4. Have you a history of, or do you have a, heart condition?

5. Do you have you a pacemaker fitted? Have you a history of, or do you have a, heart condition?

6. Have you a history of or do you have high blood pressure?

7. Have you ever had, or do you currently suffer with Chronic Neurological Disease (e.g. Parkinson’s Disease or Multiple Sclerosis)?

8. Have you a history of or do you currently suffer with dizzy spells or balance problems?

9. Do you currently have a heavy cold, or do you have a chest infection?

10. Have you a history of, or do you have any, back trouble/pain?

11. Have you suffered from any whiplash injuries?

12. Do you have arthritis or joint pain of any sort?

13. Have you broken any bones in the last year or previously that you feel may affect your ability to take part? NB: a fracture and a break are the same thing!

14. Do you have diabetes?

15. Do you have asthma or any respiratory limitation?

16. Have you ever had, or do you currently suffer with blackouts, fits, epilepsy or fainting?

17. Are you anaemic?

18. Are you, at present, on any form of medication that you feel may affect your ability to take part in the course?

19. Have you had any operations within the last 6 months that you feel may affect your ability to take part in the course?

20. Do you have a prosthesis, joint replacement or implant?

21. Have you ever had, or do you currently suffer with hearing difficulties, eye disease or significant eyesight problems?

22. Have you have seen a doctor, or other health care professional, in the last 3 months with any concern that may affect your ability to take part in the course?

23. Is there any other reason, physical, emotional or psychological a symptom, condition or limitation that may restrict or prevent you from safely taking part or carrying out Physical Intervention / Restraint or Breakaway physical skills / procedures?

IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE EXPLAIN MORE BELOW.

DECLARATION

I have read and understood the above information and have completed this questionnaire honestly and accurately. I am aware that GSA physical intervention / restraint and breakaway training has a physical element and agree that, to my knowledge, I am physically able to participate in the training provided.
I understand that it is my responsibility to inform the tutors of any change in my health status prior to attending or during physical intervention / restraint or breakaway physical skills training.

Health Questionnaire

Health Questionnaire

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