Competitors Medical History Form

							                          Competitor’s Medical History Form

Name of Driver
Age                                    Sex

Name of Co-Driver
Age                                    Sex

   Particulars                           Driver                          Co-Driver
  Blood Group

  Diabetes
                                         Yes/No                           Yes/No
  Family History
                               Yes/No, if yes Mother/Father    Yes/No, if yes Mother/Father
  Hyper Tension
                                         Yes/No                           Yes/No
   Family History
                               Yes/No, if yes Mother/Father    Yes/No, if yes Mother/Father
  Cardiac Disease
                                         Yes/No                           Yes/No
   Family History
                               Yes/No, if yes Mother/Father    Yes/No, if yes Mother/Father
  Asthma
                                         Yes/No                           Yes/No
   Family History
                               Yes/No, if yes Mother/Father    Yes/No, if yes Mother/Father
  Epilepsy
                                         Yes/No                           Yes/No
   Family History
                               Yes/No, if yes Mother/Father    Yes/No, if yes Mother/Father
  Allergies to Drugs
                                         Yes/No                           Yes/No
  If yes please specify
  Name of drug

  Allergy


  Signatures and Date



Above information is required as precautionary measure in case of emergency.