Forms to be completed will be sent by email
PART A – PERSONAL DETAILS
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?
Are you liable to epileptic seizures or sudden
disturbances of the state of consciousness?
Do you suffer problems with heart rhythm, or have a
disease of the heart or arteries?
Do you have abnormal blood pressure that is not well
controlled with drugs?
Do you have diabetes?
Have you had a stroke, or unexplained loss of
Have you had a severe head injury with continuing
Do you suffer from parkinson's disease or multiple
Are you being treated for psychological or nervous
Have you had an alcohol or drug dependency problems
within the last 5 years?
Do you have profound deafness or any other impairment
which affects your ability to communicate clearly on the
Do you suffer from double or tunnel vision?
Do you have any other condition which could have an
adverse effect on your ability to participate in this even.t
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
Signature of Applicant_________________________________ Date__________________