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  • Medical Questionnaire Certificate

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    This 3 sentence summary provides the key details from the medical questionnaire certificate: The document is a medical questionnaire for participants of a 45km trail run that requires completion prior to commencement due to the terrain and weather conditions. It collects contact and medical history information, and assesses vital signs, physical abilities, and certifies medical clearance. Participants must submit the fully completed form to the trail leader before departing on the run.

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    KrugerPark Medical questionnaire Certificate

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    medical_questionnaire_certificate

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    This 3 sentence summary provides the key details from the medical questionnaire certificate: The document is a medical questionnaire for participants of a 45km trail run that requires completion prior to commencement due to the terrain and weather conditions. It collects contact and medical history information, and assesses vital signs, physical abilities, and certifies medical clearance. Participants must submit the fully completed form to the trail leader before departing on the run.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    5 views1 page

    Medical Questionnaire Certificate

    Uploaded by

    hggqelmqtwrkgorfoh
    This 3 sentence summary provides the key details from the medical questionnaire certificate: The document is a medical questionnaire for participants of a 45km trail run that requires completion prior to commencement due to the terrain and weather conditions. It collects contact and medical history information, and assesses vital signs, physical abilities, and certifies medical clearance. Participants must submit the fully completed form to the trail leader before departing on the run.

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    © All Rights Reserved
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    of 1

    TRAIL MEDICAL QUESTIONNAIRE CERTIFICATE FOR PARTICIPANTS

    (Due to the terrain, weather conditions and distance of approximately 45km, it is compulsory for the
    completion of this document prior to commencement. This certificate must be completed in full
    and handed to the Trailer Leader prior to departure)

    PARTICIPANT: ……………………………………………………… IDENTITY NUMBER: ……………………………………….

    CONTACT DETAILS. OFFICE HOURS: ………………………………………….. MOBILE: …………………………………….

    ADDRESS: …………………………………………………………………………………………………………………………………………

    NEXT OF KIN: ……………………………….. CONTACT DETAILS: MOBILE: ……………………………………………………

    DOCTOR: ……………………………………… CONTACT DETAILS: OFFICE HRS: ………………………………………………

    THIS MEDICAL CLEARANCE IS VALID FOR THIRTY (30) DAYS ONLY


    1. Any previous serious illnesses or operations: ……………………………………… ……………………………………….

    2. Any history of epilepsy, blackouts, heat exhaustion, serious allergies to bee-sting or snake serum:
    …………………………… ……………………………………… ………………………………………… ………………………………………..

    3. Serious nervous disorder: ……………………………………………………………………………………………………………..

    4. General appearance and muscle development: …………………………………….. …………………………………….

    5. Pulse (before and after exercise): Before: ……………… After: ………………….

    6. Blood pressure (before and after exercise): Before: …………..... After: ………………….

    7. Condition of heart and circulatory system: …………………………………………………………………………………..

    8. Condition of respiratory system: ……………………………………………………………………………………………………

    9. Tendency to: (a) Peptic Ulcers: ……………………………….. (b) Diarrhoea: …………………………………………….

    10. Abnormality of speech, gait, co-ordination: …………………………………………………………………………………

    11. Eyesight: Left: …………………………… Right: ……………………………….

    12. Hearing: Left: ……………………………. Right: ……………………………….

    13. Sensory abnormalities: …………………………………………………………………………………………………………………

    14. Abnormality of the skeleton or limbs: …………………………………………………………………………………………..

    15. Urine test: (a) Albumen: .............................. (b) Sugar: …………………………

    MEDICAL CLEARANCE: APPROVED / REJECTED

    SIGNATURE OF PRACTITIONER ……………………………………………

    DATE / PRACTITIONER STAMP

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