Physical Examination Form For A Competition License Page 2
Download a blank fillable Physical Examination Form For A Competition License in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Physical Examination Form For A Competition License with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3P
E
F
C
L
(To be fully completed, signed and dated by a Medical Doctor and returned to candidate)
Failure to fully complete required informa on will delay the processing of your applica on
Name
Age
Birthdate
Street Address
City/State/Zip
Sex
Height
Weight
Color of Hair
Color of Eyes
Blood Pressure
Pulse
Respira ons
NOTE: Medical forms from candidates having the following afflic ons or taking prescribed medica ons must be referred to the PCA Club
Racing Commi ee for review. Medical forms for referral must be received in a mely fashion.
1.
Less than 20/40 corrected vision in the be er eye
5. Loss of extremity or eye
9. Epilepsy
2.
Alcoholic or drug addic on
6. Diabetes
10. History of Heart A ack
3.
Blood pressure: Diastolic over 90, systolic over 160
7. Loss of color vision
4.
All gross deformi es subject to lis ng
8. Psychological problems
VISION
Abnormali es require an a ached ophthalmology consult
Vision OD
OS
OU
Color Vision
Test Name
Peripheral Vision (degrees from midline)
OD
OS
Test Name
NEUROLOGICAL
Abnormali es require an a ached neurology consult
Reflexes: Normal
Abnormal
Cerebellar: Normal
Abnormal
Other tests performed
CARDIAC
Abnormali es require an a ached cardiology consult
At age 40, a baseline EKG should be performed. Further EKGs need to be completed only if the candidate is a smoker, has a cardiac
history, a strong family history of cardiac disease, history of diabetes, or has hypertension (systolic > 140, diastolic >90).
Cardiac Exam: Normal
Abnormal
Please a ach a copy of EKG results
METABOLIC
Please a ach an HgbA1c and medical consult for any history of Diabetes
History of Diabetes: Yes
No
HgbA1c (less than 10)
Comments or concerns that the PCA Club Racing Commi ee should be aware of:
Comments regarding current medica ons the applicant is taking (any side effects):
Examining Physician’s Comments regarding medical history:
RE‐EXAMINATION
: It is the responsibility of the applicant to present him/herself for re‐examina on as follows:
1. Upon expira on of his/her current medical examina on form as required by the current PCA Club Racing Rule Book for
ANNUAL (1 year) EXAMINATION
BIENNIAL (2 year) EXAMINATION
(check one)
2. Following any significant illness, injury, or hospitaliza on experienced a er this Physical Examina on
On the basis of this limited examina on, review of the applicant’s history, and the instruc ons addressed to me, I
(check one)
Find the applicant medically fit to par cipate in the sport of compe
ve racing at the present me
Recommend the candidate’s medical history be reviewed by the PCA Club Racing Commi ee
Find the applicant medically NOT fit to par cipate in the sport of compe
ve racing at the present me.
OFFICIAL STAMP or CARD HERE (required)
Signed
(examining physician)
Address
Date:
City, St, Zip
Phone Number
PCA CLUB RACING
1897 MISSION HILLS LANE
NORTHBROOK, IL 60062
phone: 847.272.7764
fax: 847.272.7785
page 2 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical