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Medical Questionnaire Form
Competitor's Name
Email
Phone number
Do you have any allergies to any medications?
If you answered yes, please indicate which medications.
Do you take any medications regularly?
If you answered yes, please indicate which medications.
Do you wear contact lenses?
Do you have a history of any of the following conditions?
epilepsy (seizures)
lung disease
heart disease
diabetes
high blood pressure
If you answered YES to any part of question four, please complete question five
I hereby state that I am under the care of a physician and that I have been medically cleared by that physician to participate in this tournament.
Physician's Name
I hereby certify that the above information is true and accurate to the best of my knowledge.
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