Driver Medical Form

Completing this Driver Medical Form is for the benefit of assessing and treating a driver should an emergency arise. By completing this form, you acknowledge that you have willingly and truthfully completed all the designated fields as requested by the CARS Tour West.

CARS Tour West will mantain the privacy of the Drivers and not disclose any of the information from this Driver Medical Form to any other party unless deemed necessary for proper treatment in the event of a medicial situation as part of a CARS Tour West releated event.

Name*

First NameLast Name

Age*

Weight*

Are you allergic to any medication?*

YesNo

If Yes, please list medication you are allergic to:*

Are you now on any prescribed medication on a permanent or semi-permanent basis?*

YesNo

If yes, please list medications*

Are you now on any prescribed medication on a permanent or semi-permanent basis?*

YesNo

Are you taking medication to treat diabetes (insulin or pills)?*

YesNo

If yes, please list medications.*

Do you wear contact lenses during competition?*

YesNo

Have you been informed by a medical doctor that you have Asthma?*

YesNo

If yes, what, if any, asthma medications do you take regularly?*

Do you wear any dental appliances?*

YesNo

Have you ever had an injury to your neck involving nerves, vertebrae or discs that incapacitated your for a week or longer?*

YesNo

If yes, give the dates of each such injury. *

Have you ever had an Epileptic Seizure or been diagnosed with Epilepsy?*

YesNo

Have you ever experienced a concussion within the past 3 years?*

YesNo

If yes, give dates of each incident.*

CARS Tour West Driver Medical Form