Brenscombe Outdoor Centre. click for home.

BRENSCOMBE OUTDOOR CENTRE
Studland Road, Corfe Castle, Dorset BH20 5JG
01929 481 222

Leading in outdoor education since 1992

Group Medical Form

Please complete and submit this form online. If you cannot submit the form online it can be downloaded here.

Group Name(*)
Please provide your group name.

Group Leader Name(*)
Invalid Input

Contact E-mail(*)
Invalid email address.

Re-enter email(*)
This email address does not match

Start date for the visit(*)
Please select the start date for your visit

Your Enquiry Number
Invalid Input

In your group are any of the participants UNABLE TO or SUFFER from the following?

Perform moderate exercise?
Invalid Input

Names of any individuals unable to perform moderate exercise
Invalid Input

Comments for individuals unable to perform moderate exercise
Invalid Input

Any back, arm or leg problems(*)
Invalid Input

Names of any idividuals suffering from any back, arm or leg problems
Invalid Input

Comments for individuals suffering from any back, arm or leg problems, including any medication
Invalid Input

Asthma(*)
Invalid Input

Names of any individuals with asthma
Invalid Input

Comments for asthma sufferers, including any medication
Invalid Input

Any types of hernia(*)
Invalid Input

Names of any individuals suffering from hernia
Invalid Input

Comments for hernia sufferers, including any medication
Invalid Input

Acute fear of water (*)
Invalid Input

Names of any individuals with fear of water
Invalid Input

Comments for individuals with acute fear of water
Invalid Input

Vertigo or problems with balance (*)
Invalid Input

Names of any individuals with vertigo
Invalid Input

Comments for individuals with vertigo, including any medication
Invalid Input

Impairment of sight, hearing or speech (*)
Invalid Input

Names of any individuals with sight, hearing or speech impairments
Invalid Input

Comments for individuals with sight, hearing or speech impairments
Invalid Input

Recurring dizziness (*)
Invalid Input

Names of any individuals suffering from dizziness
Invalid Input

Comments for individuals suffering from dizziness, including any medication
Invalid Input

Migraine, headaches or taking medication (*)
Invalid Input

Names of any individuals suffering from migraines, headaches or taking medication for these conditions
Invalid Input

Comments for individuals suffering from migraines or headaches, including any medication
Invalid Input

Hay fever or allergies (*)
Invalid Input

Names of any individuals suffering from hayfever or allergies
Invalid Input

Comments for individuals suffering from hayfever or allergies, including the allergin(s) and medicaton
Invalid Input

Diabetes (*)
Invalid Input

Names of any individuals suffering from diabetes
Invalid Input

Comments for individuals suffering from diabetes, including any medication
Invalid Input

Epilepsy, seizures, convulsions or taking medication for these conditions(*)
Invalid Input

Names of any individuals suffering from epilepsy, seizures or convulsions
Invalid Input

Comments for individuals suffering from epilepsy, seizures or convulsions, including any medication
Invalid Input

High blood pressure (*)
Invalid Input

Names of any individuals suffering from high blood pressure
Invalid Input

Comments for individuals suffering from high blood pressure, including any medication
Invalid Input

History of heart attacks / angina(*)
Invalid Input

Names of any individuals with a history of heart attack or angina
Invalid Input

Comments for individuals with a history of heart attack or angina, including any medication
Invalid Input

Take any form of medication (*)
Invalid Input

Names of any individuals taking other regular medication not listed above
Invalid Input

Comments for individuals taking regular medication, including the name of the medication
Invalid Input

Any other condition which you feel may effect participation on the programme (*)
Invalid Input

Names of any individuals with other conditions that could affect their participation
Invalid Input

Comments for these individuals, including the nature of the condition
Invalid Input