Practice Medical Form

Contact Details
Legal NameLizi Williams
EmailEmail hidden; Javascript is required.
Phone07961446464
TeamWomens Team
Date of Birth26/02/1990
Next of Kin DetailsIn the case of emergency, who is the best person to contact
NameRonnie Appleton
RelationSpouse
Phone07538480680
Travel & Accomodation Details
Travel ArrangementTrain
Travel Comments/Details

Absolute nightmare.
Leaving on Sunday.

Hotel / Accomodation NameThe Z Hotel
Others StayingAlone
Medical
Medical ConditionsYes
Condition Details

ADHD, Asthma, Restless Leg Syndrome, Severe dairy intolerance, Hayfever

Pre-existing injuriesYes
Injury Details

Some ADHD related general chronic pain, nothing of concern - stress induced.

Medication(s)Yes
Medication Details

Lisdexamfetamine 50mg AM, Ropinirole 0.25 micrograms PM, Fostair 100/6, Ventolin AM&PM, Montelukast PM, Fexofenadine (when needed).

AllerigiesYes
Allerigy Details

Penicillin

CommentsAre there any other items that you believe the Coaches/Organisations should be made aware of?
Additional Comment

I have emotional dysregulation linked to ADHD. I can sometimes have an emotion reaction that is not relative to a situation or can become overwhelmed easily. Coaches that know me well have witnessed this and understand how to manage this, newer coaches - I am happy to discuss.

Agreements
Authority reporting Approval
  • agreed
Insurance Coverage
  • agreed
Medical Release
  • agreed
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