Forms to be completed will be sent by email
PART A – PERSONAL DETAILS
Surname_________________________ Forename(s)
Home Address
___________________________________________________________Postcode
Telephone Email
Date of Birth_____________________
PART B - MEDICAL REVIEW
Please answer the following questions. If you answer “Yes” to any of the questions please provide details in the box at the bottom of this section.
Have you had a coronary thrombosis (heart attack) or
have undergone heart surgery?
Yes No
Are you liable to epileptic seizures or sudden
disturbances of the state of consciousness?
Yes No
Do you suffer problems with heart rhythm, or have a
disease of the heart or arteries?
Yes No
Do you have abnormal blood pressure that is not well
controlled with drugs?
Yes No
Do you have diabetes?
Yes No
Have you had a stroke, or unexplained loss of
consciousness?
Yes No
Have you had a severe head injury with continuing
impairment?
Yes No
MEDICAL QUESTIONNAIRE
Do you suffer from parkinson's disease or multiple
sclerosis?
Yes No
Are you being treated for psychological or nervous
problems?
Yes No
Have you had an alcohol or drug dependency problems
within the last 5 years?
Yes No
Do you have profound deafness or any other impairment
which affects your ability to communicate clearly on the
radio/telephone?
Yes No
Do you suffer from double or tunnel vision?
Yes No
Do you have any other condition which could have an
adverse effect on your ability to participate in this even.t
Yes No
If you have any additional information you would like to provide to support this Medical Questionnaire or inresponse to the above questions please use this space:
PART C - DECLARATION
I declare that I have checked the details given on the enclosed form and that to the best of my
knowledge and belief they are true and correct. I also authorise Calabaza Sailing l to disclose the information in
this form to the Calabaza Sailing Insurance Assessor and agree to submit to a medical examination if requested by
the Insurance
Signature of Applicant_________________________________ Date__________________