The annual health questionnaire is required for all PRO Rally licenses. A physical examination (see other side) is required only if there is a yes answer to health questions 1 - 10 below.
Name______________________________________Age______Birthdate__________________________________ Street Address____________________________City__________________________State_______Zip_______ Region of Record__________________________Occupation__________________________________________ HEALTH QUESTIONS: Yes No 1. Have you been admitted to the hospital in the past 12 months? _______ ______ 2. Have you been treated for heart disease, heart attack, or angina? _______ ______ 3. Have you been treated for seizures, epilepsy, or blackout spells? _______ ______ 4. Have you been treated for diabetes? _______ ______ 5. Have you been treated for allergic asthma or lung disease? _______ ______ 6. Have you been treated for alcohol or drug dependency? _______ ______ 7. Are you under a doctors care for any chronic illness? _______ ______ 8. Have you lost the use of any extremity (amputation / paralysis)? _______ ______ 9. Do you take prescription medications for any chronic medical condition (not including birth control pills, antibiotics, allergies)? _______ ______ 10. Have you been treated for psychological illness, suicide, depression? _______ ______ PLEASE COMPLETE THE FOLLOWING: 1. Date of last physical examination___________________________________________________________ 2. Date of last tetanus booster________________________________________________________________ 3. List of current medications_________________________________________________________________ 4. List any operations (with in the last five years)___________________________________________ 5. List any hospitalizations (with in the last five years)_____________________________________ 6. List any allergies, hay fever_______________________________________________________________ 7. List any previous SCCA waiver for medical problems__________________________________________ 8. Name of regular physician Address_________________________________ City __________________________ State_______ Zip______ Remarks________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ This is to certify that the above statements are true and accurate. The penalty for falsifica- tion is the loss of competition license. I also give my permission to any hospital,institution. or physician to furnish any information relative to my condition to the SCCA. Print Name____________________________________________________ Date___________________________ Applicants Signature__________________________________________________________________________ If you hove any questions regarding the need for a physical examination, contact the SCCA PRO Rally Medical Administrator, Floyd "Doc" R. Shrader, M.D., (501)732-5511wk,(501)732-3433hm.