MEDICAL HISTORY FORM

Have you ever had, or are now being treated for any of the following?

	YES	WHEN
Heart Disease
High Blood Pressure
Rheumatic Fever
Tuberculosis, Asthma, or Lung Disease
Liver Disease
Kidney Disease
Diabetes
Surgery in the last 5 years (if so, please indicate below)
Drug Allergies (if so, please indicate below)
Are you currently taking any medications (if so, please indicate below)
Are you allergic to bee stings

Comments regarding positive answers to any of the above:

If any of these medical problems should develop between the time you submit your entry form and race day, please alert race management so that we may be aware of the situation.

I hereby declare that the answer(s) to the above questions are true and as accurate as possible.

Signature:___________________________________________Date: ______________________

This form must accompany your entry form. Race management reserves the right to reject any entry, if it is felt that the applicant's present medical condition could be jeopardized by participation in this event.