PLAYER WELFARE PROFILE FORM

MALAYSIA RUGBY LEAGUE

PLAYER DETAILS
Full IC/Passport No:
Name:

Team: Playing Personal Contact No:

Position:

Residential Address: Emergency Name &

Contact No:

Completed World Rugby Concussion Management for the General Public? Date of WR certificate:
https://playerwelfare.worldrugby.org/concussion

MEDICAL BACKGROUND*
Allergies and type of reaction/s: Medications for medical problem/s:

Past Medical / Surgical History: Personal / health /medical insurance: Yes / No

Details of insurance policy:

HISTORY OF RECENT INJURIES (FOR THE PAST 6 MONTH)*

Type of Injury (e.g. shoulder When (date Nature of treatment Who treated you (e.g.
dislocation/ ACL /concussion) & year) received doctor/ physio/ self) &
where

BASELINE PHYSICAL EXAMINATION*

Weight: Height: Blood Heart
/
kg cm Pressure: mmHg Rate: bpm
Heart: Eye Vision Acuity R: L:
/ /
(with/without aids)
Lungs: MSK:

Abdomen: Others:

DECLARATION
All the above information provided in this form is complete, true and accurate to the best of my knowledge
and I am physically, dentally and mentally FIT to play competitive rugby.
Player Doctor/ Team Medical Official (Qualified medical
Signature: officer or healthcare professional)
Name / Date:
Signature:
Head Coach / Team Manager Name / Date:
Signature: Official stamp:
Name / Date: Contact No:
Contact No:

Notes: * Please fill in all the sections and include attachments where appropriate. Please provide a copy of the completed team forms to
the Tournament Director for administrative purpose.
MALAYSIA RUGBY MEDICAL 2019