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Addo Elephant Trail Runs 2009 |
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Medical Details (to be complete by participant) |
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COMPLETE FORM AND FAX TO: +27 (0)86 609 7755 BY 20 March 2009 |
| Which event have you entered: |
| General |
| First Name: Surname: |
| Contact Telephone Numbers (incl. code) Work: |
| Home: Mobile: |
| Date of Birth: Age on 01 MAY 2009: |
| Medical Aid and Number (South Africans only) |
| Main Member (if not you) |
| Next of Kin (In event of emergency) |
| Name: Relationship: |
| Contact Number: |
| Family Doctor: Contact Number: |
| Medical Information - History |
| (All information is strictly confidential) |
| 1. Do you use any performance enhancing medication? YES NO |
| 2. Are you on any chronic medication? YES NO |
| 3. DO YOU SUFFER FROM ANY ONE OF THE FOLLOWING: |
| a. Cardiovascular Problems YES NO |
| b. Respiratory Problems YES NO |
| c. Endocrine Problems (Diabetes) YES NO |
| d. Musculoskeletal Problems YES NO |
| e. Central Nervous System Disorders (Fainting, epilepsy etc) YES NO |
| f. Major Illness within Last Year YES NO |
| g. Gastro Intestinal Problems YES NO |
| h. Any Family History of Heart Disorders YES NO |
| If your have answered yes to any of the above, supply comprehensive details. |
| 4. Have you undergone any surgical procedures in the last two years? NO YES |
| If yes, give details |
| 5. Are you allergic to anything? NO YES (details) |
| 6. Have you ever suffered from a heat disorder/anaesthetic problem? NO YES |
| 7. Are you currently taking medications? NO YES (details) |