Addo Elephant Trail Runs 2009

Medical Details (to be complete by participant)

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)