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General Services

Association
PRE-TRAINING HEALTH SCREEN
This document is for use at GSA training courses and update sessions.
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.
All questions must be answered.
If yes, please explain. Include any medication
management and how this influences your daily life.

Have you a history of, or do you have


a, heart condition?

Yes

No

Do you have you a pacemaker fitted?

Yes

No

If yes, please explain. Include any medication,


management and how this influences your daily life.

Have you a history of or do you have


high blood pressure?

Have you ever had, or do you currently


suffer with Chronic Neurological
Disease (e.g. Parkinsons Disease or
Multiple Sclerosis)?

Have you a history of or do you


currently suffer with dizzy spells or
balance problems?

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Yes

No

If yes, please explain. Include any medication


management and how this influences your daily life.

Yes

Yes

No

No

If yes, please explain. Include any medication,


management and how this influences your daily life.

Do you currently have a heavy cold, or


do you have a chest infection?

Have you a history of, or do you have


any, back trouble/pain?

Have you suffered from any whiplash


injuries?

Do you have arthritis or joint pain of


any sort?

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!

If yes, please explain:

Yes

Yes

No

No

If yes, please explain. Include any current or previous


management (treatment, therapy or medication), and
how this influences your daily life.

If yes, please explain. Include any current or previous


management (treatment, therapy or medication), and
how this influences your daily life.

Yes

No

If yes, please explain. Include any current or previous


management (treatment, therapy or medication), and
how this influences your daily life.

Yes

Yes

No

No

If yes, please explain. Comment on the area, method of


injury (i.e. was this due to trauma or osteoporosis?), and
any residual discomfort or limitation of movement which
currently exists as a result of the injury.

If yes, please explain. Include any medication,


management and how this influences your daily life.

Do you have diabetes?

Yes

Do you have asthma or any respiratory


Yes
limitation?

Have you ever had, or do you currently


suffer with blackouts, fits, epilepsy or
fainting?

No

If yes, please explain. Include any medication,


management and how this influences your daily life.

No

If yes, please explain. Include any medication,


management, frequency and type of seizures and how
this influences your daily life.

Yes

No

If yes, please explain. Include any medication,


management and how this influences your daily life.

Are you anaemic?

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Yes

No

Are you, at present, on any form of


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

Yes

No

If so please explain. Include any medication,


management and how this influences your daily life.

If so please explain:

Yes

No
If so please explain:

Do you have a prosthesis, joint


replacement or implant?

Have you ever had, or do you currently


suffer with hearing difficulties, eye
disease or significant eyesight
problems?
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?
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
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?

Yes

No

If so please explain:

Yes

No

If so please explain:

Yes

No

If so please explain:

Yes

No

If so please give details:

Yes

No

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.
Name (in capitals):

Date of Birth:

Contact Tel No.

Signed:

Date:

Signed:

Date:

Tutor Name:

Comments / Advice Given:

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