Medical / Biodata Screening

Please note all information will be kept strictly confidential. Team/emergency med
Name

Name of the Assessor

Cricket Information (tick and/or circle):
Batsman (L/R)

All-Rounder

Pace Bowler (L/R)

Throw with left arm

Spin Bowler ( L / off / leg )

Throw with right arm

Wicketkeeper

Date of Birth
Mobile No
Any relevant ongoing or past medical conditions (e.g. diabetes, epilepsy, asthma, allergies etc)?

Any current/regular medications/TUE's ?

Any relevant past surgeries; Y N (please list ALL relevant);

Orthotics? Y N

Veg/Non-veg/Other?

Injury History
Include the side of the body and the date of injury of any current AND/OR past injuries or symptoms
Head/Face/Jaw
Neck
Shoulder
Elbow/forearm

Wrist/Hand/Finger
Chest/Upper Back
Ribs/Abdomen
Lower Back
Buttocks
Groin/hip
Thigh (front/back)
Knee
Shin/Calf
Ankle/Foot/Toes

/emergency medical use only

Date

Age

es etc)?

eg/Other?

r symptoms

LOAD RECORD
Have you been playing
matches in the
previous 4 weeks?

Y/N

Matches
Last Week
2 Weeks Back
3 Weeks Back
4 Weeks Back
Have you been training
in the previous 4
weeks?

Y/N

Sessions
Last Week
2 Weeks Back
3 Weeks Back
4 Weeks Back
How many overs have
you bowled recently?

Y/N
Overs

Last Week
2 Weeks Back
3 Weeks Back

4 Weeks Back

ORD

When was your last match?

When was your last training session?

Cricket Format?

STANDING MEASURES

LEFT

RIGHT

LEFT

RIGHT

Knee to wall
Single Leg Squat Flat
Star excursion test
Lumbar flexion
Lumbar extension
Lumbar lateral flexion
Lumbar quadrant
Shoulder elevation (sagittal)
Shoulder elevation (frontal)
Shoulder Horizontal add
Shoulder HBB
Hawkins Kennedy
O'Brien's Test
Empty Can

SEATED

Test
Hip IR 90
Hip ER 90

Slump Test
Cervical flexion

Cervical rotation

Cervical extension
Cervical lateral flexion
Thoracic rotation
Thoracic extension
Thoracic lateral flexion

SUPINE

LEFT

RIGHT

LEFT

RIGHT

LEFT

RIGHT

Lying to long sit malleoli

1st MTP Extension
Shoulder ER at 90
Shoulder IR at 90 side lie
Shoulder Relocation
FABER
Passive SLR
Active Knee Extension
Groin squeeze 60
Hip quadrant

PRONE
Hip IR 0
Hip ER 0
Prone knee bend (R1,R2)
Combined elevation
Forced ankle PF

END OF PLINTH
Thomas test Hip Extension
Thomas test Knee Flexion
Thomas test Hip Abduction

COMMENTS

Grading/Units

Cm/degrees
Pelvis, knee, 90, Sx, Total/4
cm
L1-S1 change cm
cm - Index to popliteal crease
cm +/- distance from floor
Pain/No pain
Full/Restricted/SCAP kinesis
Full/Restricted/SCAP kinesis
cm - elbow crease line to axilla
cm - L ?? R
Pain/No pain
Pain, Weakness
Pain, Weakness

COMMENTS

Grading/Units

Grading/Units
degrees
degrees

degree KE, symmetry, +/Normal/Restricted/Sx

Normal/Restricted/Sx

Normal/Restricted/Sx
Normal/Restricted/Sx
Normal/Sx/degrees
Normal/Restricted/Sx
Normal/Restricted/Sx

COMMENTS

Grading/Units
Change in malleoli L to R
degrees
degrees
degrees
Pain/no pain/improved ROM
Sx, R=L
degrees
degrees
mmHg
Sx reproduction

COMMENTS

Grading/Units
degrees
degrees
degrees
degrees
Sx reproduction

COMMENTS

Grading/Units
degrees
degrees
degrees

STRENGTH

LEFT

RIGHT

Calf endurance
Groin squeeze
Hip abduction
Hip adduction
Hip flexion

TEST 27 - POSTURAL ASSESSMENT

Head

Thoracic Spine

Neutral
Neutral
Neutral
Neutral

Lumbar Spine

Neutral

Pelvis

Neutral

Shoulders

Knees

Left
Right

Left
Right

Neutral
Neutral

Left
Foot
Right

KEY FINDINGS
Tightness

Weakness

STRENGTH

LEFT

Hamstring 90/90 bridge

Shoulder ER at 90
Shoulder IR at 90
Shoulder ER at 0
Shoulder IR at 0

ST 27 - POSTURAL ASSESSMENT
Forward
Elevated / Depressed
Elevated / Depressed
Flattened / Kyphosis

Neutral / Rounded
Neutral / Rounded
Scoliosis

Increased / Decreased Lordosis

Anterior / Posterior tilt

Left / Right / Raised

/Lowered

Varus / Valgus
Varus / Valgus
Medial Arch = Flat / High / Norm

Neutral / Hyperpronated

Medial Arch = Flat / High / Norm

Neutral / Hyperpronated

KEY FINDINGS
Posture

Notes

RIGHT

WORK LOAD MONITORING SHE

Week 1 Activity
Day

RPE

Week 2 Mins

Workload Factor

RPE

Mins

MONDAY

MONDAY

TUESDAY

TUESDAY

WEDNESDAY

WEDNESDAY

WEDNESDAY

WEDNESDAY

THURSDAY

THURSDAY

FRIDAY

FRIDAY

Gym Session
Running Session
Match
Skill Practice
Acute Workload Sub - Total
Day

Gym Session
Running Session
Match
Skill Practice
Acute Workload Sub - Total
Day

Gym Session
Running Session
Match
Skill Practice
Acute Workload Sub - Total
Day

Gym Session
Running Session
Match
Skill Practice
Acute Workload Sub - Total
Day

Gym Session
Running Session
Match
Skill Practice
Acute Workload Sub - Total
Day

Gym Session
Running Session
Match
Skill Practice
Acute Workload Sub - Total
Day

SATURDAY

SATURDAY

SUNDAY

SUNDAY

Gym Session
Running Session
Match
Skill Practice
Acute Workload Sub - Total
Day

Gym Session
Running Session
Match
Skill Practice
Acute Workload Sub - Total
TOTAL ACUTE WORKLOAD
TOTAL ACTIVITY WISE WORKLOAD

- GYM SESSION
- RUNNING SESSION
- MATCH
- SKILL PRACTICE

OAD MONITORING SHEET

Week 3 Workload Factor

RPE

Week 4 Mins

Workload Factor

RPE

Mins

MONDAY

MONDAY

MONDAY

TUESDAY

TUESDAY

TUESDAY

WEDNESDAY

WEDNESDAY

WEDNESDAY

WEDNESDAY

WEDNESDAY

WEDNESDAY

THURSDAY

THURSDAY

THURSDAY

FRIDAY

FRIDAY

FRIDAY

Workload Factor

SATURDAY

SATURDAY

SATURDAY

SUNDAY

SUNDAY

SUNDAY

RATE OF PERCEIVED
EXERTION

10
9
7-8
4-6
2-3
1

Max Effort Activity

Feels almost impossible to keep going. Completely
out of breathe, unable to talk

Very Hard Activity

Very difficult to maintain exercise intensity.
Can barely breath & speak a single word

Vigorous Activity
On the verge of becoming uncomfortable
Short of breath, can speak a sentence

Moderate Activity
Feels like you can exercise for hours.
Breathing heavily can hold short conversation

Light Activity
Feels like you can maintain for hours
Easy to breathe & carry a conversation

Very Light Activity

Anything other than sleeping
Watching TV, riding in a car, etc.