Addo Elephant Trail Runs - Confidential Medical Questionnaire

(EMAIL THE COMPLETED FORM TO nadia@extrememarathons.com OR FAX TO: +27 (0) 86 609 7755)

General

First Name:

Surname:

Age:

ID No:

Family Doctor:

Contact Number:

Contact Details in event of emergency

Name:

Contact Number:

Medical Information/History (Information is confidential and is given to the Event Medical Team)

 

Yes

No

Do you use any Performance Enhancing Medication

 

 

Are you on any Chronic Medication

 

 

Do you suffer from any one of the following:

 

 

1. Cardiovascular Problems

 

 

2. Respiratory Problems

 

 

3. Endocrine Problems (Diabetes)

 

 

4.Musculoskeletal Problems

 

 

5. Central Nervous System Disorders (Fainting, epilepsy, etc)

 

 

6. Major Illness within last year

 

 

7. Gastro Intestinal Problems

 

 

8. Any family history of Heart Disorders

 

 

If you have answered YES to any of the above, supply details:

 

 

 

YES

NO

Have you undergone any surgical procedures in the last two years?

 

 

If yes, give details:

 

Are you allergic to anything?

 

 

If yes, give details:

 

Have you ever suffered from a heat disorder or anaesthetic problem?

 

 

If yes, give details:

 

Are you currently taking medications?

 

 

If yes, give details: