8/17/2019 Zambia Motorsports Association Medical Form
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ConfidentialZAMBIA MOTOR SPORTS ASSOCIATION
RALLY COMMISSIONForm for Medical Examination of Applicant for
Rall!in" Competition Licence
A# PERSONAL STATEMENT MA$E BEFORE A ME$ICAL PRACTITIONER
Applicants Name (in
full):_________________________________________________________________________
Address:__________________________________________________________
Phone No.:_________________
Email:_________________________________
NB# APPLICANT IS RESPONSIBLE FOR ANY FEE OF T%E ME$ICAL
PRACTITIONER
1 Date of Birth
2 What alcohol do you consume and whatquantity per day/week?
3 Do you take sedatives or drugs of any kind?
!ave you" or have you ever had any of thefollowing (if so, give
full details)#$i% fits" tremors" an&iety neurosis" or
othersimilar medical complaint?
$ii% palpitation" faintness" a shortness of 'reath"chest pains"
high or low 'lood pressure" orother affection of the heart of
circulatorysystem?
$iii% Dia'etes or sugar in urine?
( Do you have any physical a'normality?
) !ave you ever had a serious head in*ury?
+ !ave you consulted any medical practitioner orvisited any
hospital/clinic in respect of anyin*ury or illness in the past 12
months?(if so, give full details)
, -ive the name and address of your usualmedical attendant.
0re there any circumstances" however minor"that may increase the
risk of your taking part incompetitive motor sport?
$ECLARATION OF APPLICANT& understand that the answers that
have given to the questions a'ove are true and complete and that
any misstatementor concealment of fact on my part may lead to the
withdrawal of my competition license.
igned# at
Date# Witnessed#
T%E ME$ICAL PRACTITIONER IS RE'(ESTE$ TO COMPLETE T%IS
CERTIFICATE AN$ %AN$ TO APPLICANT
certify that is considered medically fit/unfit (delete
asapplicable) to compete in motor sport.
igned# Date# Doctor4s tamp#
8/17/2019 Zambia Motorsports Association Medical Form
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Not )alid *it+o,t a doctor- tamp
CONFI$ENTIAL ME$ICAL REPORT Answers (please enlarge if
thought necessary)
1 s there any a'normality in respect of theapplicants 'uild or
appearance?
2 s the respiratory system sound?
3 $i% s the pulse normal in character?
$ii% What is the 'lood pressure? ystolic# Dialstolic#
Do you consider this to 'e affected 'y theconditions of the
e&amination 5nervousness? (if so, give result afterretest|)
s there any evidence of disease to 'rain"nerves or spinal
chord?
( s there any active disease in the ears?$if so" is there any
fear of vesti'ular upset?%
) $i% s ocular movement normal and co6coordinated?
$ii% s the visual filed impaired in any way?
$iii% What is visual acculty ?7ote# Where special eye
shieldsincorporating lenses are used" the visualacculty should 'e
checked when these areworn.
-lasses 8eft 9ye :ight 9yeWith
without
$iv% s the applicant colour 'lind?
+ 0part from the a'ove stated facts" do youknow or suspect
anything unfavoura'le asregards health and ha'its $e.g.:
drugs,alcohol)
, $i% 0re there any indications of disease ofkidneys" 'ladder"
prostate" or other genital6urinary organs? (if so, state
particulars)
$ii% :esults of ;rine test?(this must be passed in the
Eaminer!s presence or surger")
Was specimen o'tained as required?
$a% is al'umen present?
$'% is sugar present?
$c% is there any macroscopic evidence ofother a'normal
su'stances" such as 'ile"'lood" pus" or threads?
Blood -roup?
1< !ow long and in what capacity have youknown the
applicant?
=aking n to consideration that the applicant will 'e taking part
in competitive motor sport" and inparticular motor racing events"
do you consider he/she is a suita'le person to 'e granted
acompetition licence# (if ans$er is in the negative, please
enlarge)
7ame of
>edical 9&aminer# igned#
Date# lace# Doctor4s tamp#
0ddress#
PLEASE RET(RN TO& ZMSA. RALLY COMMISSION BY EMAIL FOR T%E
ATTENTION OF & T+e Secretar!. ZMSA
Rall! Commiion on email /ma0iconnect#/m and1 or
rall!commiion0"mail#com
mailto:[email protected]:[email protected]:[email protected]:[email protected]
