Confidential

ZAMBIA MOTOR SPORTS ASSOCIATION

RALLY COMMISSION
Form for Medical Examination of Applicants for Rallying Competition Licences

A. PERSONAL STATEMENT MADE BEFORE A MEDICAL PRACTITIONER

Applicants Name (in full):_________________________________________________________________________
Address:__________________________________________________________ Phone No.:_________________
Email:_________________________________
NB. APPLICANT IS RESPONSIBLE FOR ANY FEE OF THE MEDICAL PRACTITIONER
1

Date of Birth

What alcohol do you consume and what

quantity per day/week?

Do you take sedatives or drugs of any kind?

Have you, or have you ever had any of the

following (if so, give full details):
(i) fits, tremors, anxiety neurosis, or other
similar medical complaint?
(ii) palpitation, faintness, a shortness of breath,
chest pains, high or low blood pressure, or
other affection of the heart of circulatory
system?
(iii) Diabetes or sugar in urine?

Do you have any physical abnormality?

Have you ever had a serious head injury?

Have you consulted any medical practitioner or

visited any hospital/clinic in respect of any
injury or illness in the past 12 months?
(if so, give full details)

Give the name and address of your usual

medical attendant.

Are there any circumstances, however minor,

that may increase the risk of your taking part in
competitive motor sport?

DECLARATION OF APPLICANT:
I understand that the answers that I have given to the questions above are true and complete and that any misstatement
or concealment of fact on my part may lead to the withdrawal of my competition license.
Signed:_____________________________________ at__________________________________________
Date:_______________________________________ Witnessed:___________________________________
THE MEDICAL PRACTITIONER IS REQUESTED TO COMPLETE THIS CERTIFICATE AND HAND TO APPLICANT
I certify that__________________________________________________ is considered medically fit/unfit (delete as
applicable) to compete in motor sport.
Signed:_________________________ Date:_________________ Doctors Stamp:

Not valid without a doctors stamp

CONFIDENTIAL MEDICAL REPORT

1
2

Is there any abnormality in respect of the

applicants build or appearance?
Is the respiratory system sound?

(i) Is the pulse normal in character?

4
5
6

9
10

Answers (please enlarge if thought necessary)

(ii) What is the blood pressure?

Do you consider this to be affected by the
conditions of the examination
nervousness? (if so, give result after
retest|)
Is there any evidence of disease to brain,
nerves or spinal chord?
Is there any active disease in the ears?
(if so, is there any fear of vestibular upset?)
(i) Is ocular movement normal and cocoordinated?
(ii) Is the visual filed impaired in any way?

Systolic:

(iii) What is visual acculty ?

Note: Where special eye shields
incorporating lenses are used, the visual
acculty should be checked when these are
worn.
(iv) Is the applicant colour blind?

Glasses
With
without

Dialstolic:

Left Eye

Right Eye

Apart from the above stated facts, do you

know or suspect anything unfavourable as
regards health and habits (e.g.: drugs,
alcohol)
(i) Are there any indications of disease of
kidneys, bladder, prostate, or other genitalurinary organs? (if so, state particulars)
(ii) Results of Urine test?
(this must be passed in the Examiners
presence or surgery)
Was specimen obtained as required?
(a) is albumen present?
(b) is sugar present?
(c) is there any macroscopic evidence of
other abnormal substances, such as bile,
blood, pus, or threads?
Blood Group?
How long and in what capacity have you
known the applicant?

Taking In to consideration that the applicant will be taking part in competitive motor sport, and in
particular motor racing events, do you consider he/she is a suitable person to be granted a
competition licence? (if answer is in the negative, please enlarge)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
____________________________________________________________________________
Name of Medical Examiner:_____________________________ Signed:___________________
Date:____________________ Place:_________________ Doctors Stamp:
Address:______________________________________________________________________
PLEASE RETURN TO: ZMSA, RALLY COMMISSION BY EMAIL FOR THE ATTENTION OF : The Secretary, ZMSA
Rally Commission on email zmsa@iconnect.zm and/ or rallycommission@gmail.com