Medical Physical Form - 24 Items
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1
2INTERNATIONAL HOT ROD ASSOCIATION
300 CLEVELAND ROAD
NORWALK, OHIO 44857
PHONE: 419-663-6666 FAX: 419-668-6601
MEDICAL PHYSICAL FORM
Name: ________________________________ Date of Birth: ________________________
Address: ____________________________________________________________________
City: _______________________________ State: _____________ Zip: ________________
Signature: _____________________________________ Date: _______________________
MEDICAL HISTORY
HAVE YOU EVER HAD ANY OF THE FOLLOWING: (For each “yes” checked describe conditions in remarks)
Y
N
CONDITION
Y
N
CONDITION
Y
N
CONDITION
Y
N
CONDITION
a. frequent or severe
g. heart trouble
m. nervous trouble
s. medical rejection
headaches
of any sort
from service
b. dizziness or fainting
h. high or low
n. any drug or
t.
admission to
spells
blood pressure
narcotic habit
hospital
c. unconsciousness for
i. stomach trouble
o. excessive
u.
rejection for life
any reason
drinking habit
insurance
d. eye trouble except
j. kidney stone or
p. attempted
v.
record of traffic
glasses
blood in urine
suicide
convictions
e. hay fever
k. sugar or
q. motion sickness
w. record of other
albumin in urine
requiring drugs
convictions
f. asthma
l. epilepsy or fits
r. military medical
x. other illnesses
discharge
REMARKS: (if no changes since last report, so state) _______________________________________________
MEDICAL TREATMENT WITHIN THE PAST FIVE YEARS
Date
Name of Physician Consulted
Reason
_________________________________________________________________________
______________________________
SIGNATURE OF APPLICANT
DATE
APPLICANTS’ DECLARATION: I hereby certify that all statements and answers provided by me in this examination form are complete
and true to the best of my knowledge, and I agree that they are to be considered part of the basis for insurance of any IHRA certificate to
me.
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