Brighton & Hove Sea Serpents RFC Physiotherapy Team provides support to members experiencing injury, pain, or concerns affecting their participation in rugby. Please complete the form below with as much detail as possible. Urgent or emergency medical concerns should be directed to NHS 111, your GP, or emergency services.

Player Information

Full Name * Email Address * Mobile Number * Date of Birth Preferred Pronouns Emergency Contact Name * Emergency Contact Number * Player Status *

Injury or Concern Details

Body Area Affected * Please describe the injury or concern * Date Injury Started * How did the injury occur? * Was the injury related to rugby activity? *

Symptoms

Current Pain Level * Current Symptoms

Swelling Bruising Reduced movement Weakness Numbness Tingling Instability Difficulty weight bearing

Has the condition changed since it started? *

Previous Assessment or Treatment

Have you seen a healthcare professional for this issue? If yes, please provide details

Rugby Participation

Current Participation Status * What support are you seeking?

Injury assessment Rehabilitation plan Return-to-play advice Injury prevention advice Strapping / taping advice

Safety Screening

Have you suffered a concussion or head injury? * Was there any loss of consciousness? * Any urgent medical concerns?

Consent

Do you consent to the physio advising coaching staff of any participation restrictions? *

I consent to the collection and processing of this information for physiotherapy and player welfare purposes.

Brighton and Hove Sea Serpents

Hove Recreation Ground
Shirley Dr, Brighton and Hove
BN3 6NQ

contact@bhssrfc.com