Home
Tracking
Leaderboard
Latest News
Teams
8th Edition
About Primal Quest
Host Location
PQ Pure Event
PQ Pursuit Event
Schedule
Course Details
Can I do it? FAQ’s
Disciplines
Meet Our Team
Partners
Resources
Experience & Skills
Support Crews
Newsletters
Mandatory Gear List
Race Rules
Team List
Contact Us
Team Finder
Search
Sign up / Login
History
Volunteer
Volunteer
Sign Up
Resources
Medical Form
MEDICAL FORM - Competitor
ALL INFORMATION PROVIDED IS CONFIDENTIAL
Details
Team Name
Race
Pursuit
Pure
First Name
Last Name
Email Address
Home Address
Date of Birth (dd/mm/yyyy)
Age at Rate Start
Gender
Male
Female
Emergency Contact Person
Emergency Contact Phone Number
What is their relationship to you?
Emergency Contact Person’s Address
Emergency Contact Person 2
Emergency Contact Phone Number
What is their relationship to you?
Emergency Contact Person’s Address
Questions
Do you have any medical conditions currently and /or have had previously?
No
Yes
If yes, please specify what type?
Are you currently taking any medications?
No
Yes
If yes, please specify type, amounts you take, brand name and the most important cause of taking these.
Are you allergic to any medications?
No
Yes
If yes, please list:
Please list any allergies you have and if you are currently being treated for them?
Do you wear a medic alert bracelet or tattoo?
No
Yes
Have you recently experienced or been diagnosed with any of the following?
Asthma
High blood pressure
Migraine
Epilepsy
Low blood pressure
Headaches
Numbness in limbs
Dizziness
Loss of hearing
Nausea/vomiting
Fainting attacks
Irregular heartbeat
Blurred vision
Blackouts
Hepatitis
Have you had any previous injuries? (ie. Spinal injury, ligament damage or reconstruction)
No
Yes
If yes, please list:
Is there anything else pertaining to your health that we should know about (ie. chance of being pregnant?)
Do you wear contact lenses or glasses?
No
Yes
If yes, will you have spare lenses or glasses?
No
Yes
Name of your current insurance
Name of your doctor
Phone number of your doctor
Your doctor’s work address
Declaration
I declare that the information given in this form is true and complete to the best of my knowledge.
I certify that I am physically fit, have sufficiently trained for participation in the Primal Quest, and have not been advised otherwise by a qualified medical person.
I acknowledge that in accordance with the provisions of the Privacy Act 1993 the following information has been brought to my attention
This form collects personal information about me.
The intended recipients of the information are those staff directly involved with safety and medical on course.
This information is being collected and held by 100% Pure Racing and Primal Quest.
The privacy Act 1993 entitles me to have access and request a correction of the information
I declare that the information given in this form is true and complete to the best of my knowledge.
I declare