HEALTH WAIVER | Empower Futbol

Difficulties with your eyes or vision? Do you wear glasses, contact lenses for sports?

Problems with hearing? Are you using hearing aids?

Dental problems? Are you using dental prosthesis?

Difficulties with your nose or throat?

Any problems with your respiratory system or lungs? e.g., asthma, allergies to dust, tuberculosis, cough, shortness of breath, pneumonia?

Any problems with your cardio-vascular system? e.g., varicose veins, phlebitis, haemorrhoids, heart trouble, rheumatic fever, high or low blood pressure?

Any inflammatory problems? e.g., joint swelling, arthritis?

Any disease of the blood? e.g., tendency to bruising, bleeding, anaemia?

Any problems with your reproductive system/gynaecology? e.g., pain during periods, abnormal bleeding, irregular cycles, hormonotherapy, infection?

Do you currently take any medications (over the counter or prescription)?

Are you taking vitamins or any other supplements?

Are you taking any stimulants? (benzedrin, amphetamins, etc)

Are you taking any anabolic substance or growth hormone?

Are you taking sleeping pills?

None of the above

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Medical Questionnaire