10to4 MOUNTAIN BIKE CHALLENGE 2022
MEDICAL STATEMENT - Please fill the form in accurately as it will help our medical teams to service you better should you need assistance.  Tick one box to the left in response to each question. If you are unsure, please tick YES. If your response to any question is YES, you must provide further information. This form will only be checked by our medical team - your data is protected and will not be shared.

Every competitor, including children, MUST complete an individual form.
Sign in to Google to save your progress. Learn more
Full name *
Which race/s are you competing in? *
Full name of parent/guardian (if participant is under 18):
Do you have high blood pressure? *
If YES, please give details
Do you have low blood pressure? *
If YES, please give details
Are you diabetic? *
If YES, please give details
Do you suffer from any form of heart condition? *
If YES, please give details
Do you have asthma? *
If YES, please give details
Are you, or is there possibility that you are pregnant? *
If YES, please give details
Do you suffer from epilepsy or seizures? *
If YES, please give details
Have you ever experienced blackouts, loss of consciousness, or unexplained dizziness? *
If YES, please give details
Are you allergic to anything (including medication)? *
If YES, please give details
Do you suffer from high cholesterol? *
If YES, please give details
Does your family have a history of heart attacks or strokes? *
If YES, please give details
Have you had surgery in the past five years? *
If YES, please give details
Are you currently taking any prescription medication (including asthma inhalers, blood pressure drugs, etc.) *
If YES, please give details
Are you currently receiving any medical care? *
If YES, please give details
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms