PHYSICAL EXAMINATION FORM FOR A COMPETITION LICENSE
Dear Doctor:
You are being asked to examine this race driver/ patient who wish to take part in motor racing events in which it will be possible for him/her to drive a competition car at extremely high speeds under the most exacting conditions. Please, therefore, examine carefully and critically, and recommend him or her only if you are completely satisfied in all respects. An appeal process exists whereby he/she may take the matter up with physicians experienced in racing should you disapprove him/her. You will thus be doing not only the applicant but also our sport and yourself a service by conducting this examination as carefully as possible.
Candidates age 40 and over may have an EKG as part of the examination at the discretion of the physician.
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Normal |
Check each item in appropriate column (enter NE for not evaluated) |
Abnormal |
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25 |
DISTANT VISION |
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1. Head, face, neck and scalp |
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Right Eye - 20/ Corrected to 20/ |
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2. Nose |
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Left Eye - 20/ Corrected to 20/ |
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3. Sinuses |
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Both eyes 20/ Corrected to 20/ |
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4. Mouth and throat |
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26 |
Intraocular Tension : TACTILE |
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5. Ears, general |
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Right Eye - |
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6. Drums (perforations) |
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Left Eye - |
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7. Eyes, general (visual acuity under item 25) |
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27 |
Field of Vision |
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8. Opthalmoscopic |
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Right Eye - |
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9. Pupils (equality and reaction) |
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Left Eye - |
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10. Ocular mobility (associated parallel movement, nystagmus) |
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28 |
Color Vision (test) |
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11. Lungs and chest (including breasts) |
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29 |
Blood Pressure |
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12. Heart size (thrust, size, rhythm, sounds |
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Systolic |
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13. Vascular system |
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Diastolic |
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14. Abdomen and viscera (including hernia) |
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30 |
Pulse Resting - |
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15. Anus & rectum |
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After exercise |
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16. Endocrine system |
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2 minutes after exercise |
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17. G-U system |
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31 |
Urinalysis |
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18. Upper and lower extremities (strength and range) |
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Albumin |
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19. Spine, other musculoskeletal |
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sugar - |
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20. Identifying body marks, scars, tattoos |
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32 |
Other tests |
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21. Skin and lymphatics |
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33 |
EKG Results |
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22. Neuralgic (tendon reflexes, equilibrium, senses, coordination, etc. |
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Normal_______ Abnormal________ |
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23. Psychiatric (specify any personality deviations) |
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24. General systemic |
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34. Medical treatment within the past 5 years:
Date: _________ Name and address of physician consulted _______________________________________________________________
Reason: _________________________________________________________________________________________________________
________________________________________________________________________________________________________________
35. Comments on History and Findings __________________________________________________________________________________
_______________________________________________________________________________________________________________
Re-examination: It shall be the responsibility of the applicant to present himself for re-examination as follows:
a. Upon expiration of his current medical examination, this is yearly.
b. Following any significant illness, injury or hospitalization.
The applicant should have no established medical history or clinical diagnosis that may reasonably be expected, within one year after finding, to make him/her unable to perform the duties as described above. On the basis of the above information, and mindful of the note addressed to me, I make the following recommendation:
-- That the applicant is physically and psychologically fit to drive a racecar at high speed and in competitive events.
-- That the applicant must receive a review and clearance for a needed specialty physician.
-- That the applicant is NOT physically and psychologically fit to drive a racecar at high speed and in competitive events.
Signed - ________________________________________(examining physician)
Date: - _______________ Address - ____________________________________________________________________