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Medical Form Ultra Paine® 2023
- Deadline to complete the form:
September 10, 2023
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* Indicates required question
Full name
*
Your answer
Email address
(Here you will receive an email confirming receipt of your medical form)
*
Your answer
Passport number
*
Your answer
Distance
*
7K
14K
21K
35K
42K
50K
80K
Gender
*
Female
Male
Age on race day
*
Your answer
Country
*
Your answer
City
*
Your answer
In case of emergency contact:
*Emergency contact name
(Add if different from the one given in the registration form, otherwise you can skip this question and the following ones)
Your answer
Emergency contact's relationship
*Parent, Partner, Friend, etc.
Your answer
Emergency contact's phone number
*WhatsApp format (Please include Country and City code)
Your answer
Friends or family members participating in the event in case of emergency?
*
*If yes, please indicate the name/s of your friend/s, otherwise, put "No"
Your answer
Health Insurance
*
Yes
No
Health Insurance Information
*
*Insurance company name, contact, etc.
Your answer
Additional travel insurances
*
Yes
No
Insurance company name, contact and other details
Your answer
In case of having medical insurance, please indicate its main coverages.
Your answer
Blood Type and RH Factor
(Indicate if known)
Your answer
Height (m)
*
Your answer
Weight (Kg)
*
Your answer
Do you have any known allergies?
*
*Please consider: medicines, foods, insect bites, environmental agents, etc. Otherwise, put "No"
Your answer
If you answered yes, please indicate your specific reaction:
Your answer
If you answered yes, please indicate the required medication, if any:
Your answer
Do you smoke?
*
Yes
No
Have you been diagnosed with asthma?
*
*Extra field available if you want to specify anything else.
Yes
No
Other:
Have you been diagnosed with diabetes?
*
*Extra field available if you want to specify anything else.
Yes
No
Other:
Have you been diagnosed with high blood pressure?
*
*Extra field available if you want to specify anything else.
Yes
No
Other:
Have you been diagnosed with any type of heart diseases, such as arrhythmia?
*
*Extra field available if you want to specify anything else.
Yes
No
Other:
Do you have any dietary restrictions?
*
*Yes (Please Specify) or No
Your answer
Any recent drug / medication use?
*
*Please indicate cause / reason, dosis and frequency, and if you will have / use it during the race
Your answer
History of illness
*
Your answer
History of traumatic injuries
*
*Sprain, fracture, muscular injury recently or important
Your answer
Surgeries
*
*Recent or important
Your answer
Please note the date and distance of the last race or physical activity in which you participated?
*
Your answer
Have you undergone any physical exertion test or other type of cardiac exam?
*
Yes
No
If you have any medical conditions that may affect your participation in this competition, please describe them below
*
Your answer
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