2005 Rally America Rally License Medical History and Physician Examination Forms Page 1/3

Dear Doctor,

You are being asked to examine this candidate for the purpose of obtaining competition-racing privileges for a Rally America Rally License. This form concentrates on conditions and disease processes that could lead to injury or even the death of the applicant during high speed driving at a competition rally event and possibly put others at risk who are participating in, working at, or attending such an event. Please examine the candidate carefully and recommend them only if you are completely satisfied that they are capable of driving a competition rally car.

The applicant must be able to operate a race car in an environment which may contain: 1. High heat (temperatures in rally cars may exceed 20 degrees over ambient); 2. Noxious fumes and dust; 3. Very loud noise levels, high “G forces” and vibration; 4. Risks of collision, flying debris and fire.

From a physical point of view, a driver must have: 1. Mental acuity- be capable of rapid mental activity and problem solving; 2. Neuro- Musculoskeletal Integrity – the physical ability to rapidly operate the mechanical systems of the race car; 3. Good general health- minimal chance of sudden incapacitation from any disease or from drug therapy for on going treatment of stable chronic disease; 4. Good Vision- distant vision correctable to 20/30 in each eye, normal stereoscopic vision, normal color vision and peripheral vision to 70 degrees in the horizontal median for each eye. Contact lenses are permitted provided that: 1. They are certified as satisfactory for motor racing by the ophthalmic specialist who provided them; 2. They have been worn regularly (daily) for a long enough period of time (> 6 months) and for a significant period of time (>8 hours) when worn.

These illnesses or disabilities are incompatible with competition rally driving: 1. Loss of vision in one eye; 2. Epilepsy; 3. Amputations, except in the case of fingers where the gripping function in both hands is unimpaired; 4. Orthopedic appliances if the functional result is not equal to or near normal; 5.Free movement of the limbs impeded by greater than 50%.

These illness or disabilities require an assessment by the Rally America Medical Advisory Board: 1. Myocardial infarction and myocardial ischemia; valvular heart disease or other abnormal cardiovascular or peripheral vascular disease conditions; 2. Hypertension being treated with medication or greater than 140/90; 3. Asthma, Emphysema/Obstructive lung disease (COPD) or other respiratory problems; 4. Diabetes mellitus; 5. Neurological problems; cerebral vascular disease (TIA or stroke history with sequela); 6. Psychological problems; 7. A history of cold or heat exposure related illness; 8. Significant musculoskeletal or joint problems.

Cardiac testing recommendations: A base line 12 lead ECG is recommended for anyone with indications (tobacco use, personal or family cardiac disease history, HTN, hypercholesterolemia, diabetes, obesity with BMI > 30, etc.) or at 40 years of age. A cardiac stress test is recommended at age 50 years. The examining physician may require an ECG or Stress Test at any age depending on an applicant’s history and physical examination findings.

Please contact Dr. Russell Norton, Rally America Medical Delegate, by phone at 585 755 6149 with any questions or concerns.

Thank you,

Rally America Medical Advisory Board 2005 Rally America Rally License Medical History Form: To be completed by Applicant Page 2/3

Applicant: Please complete this form completely and legibly to prevent a delay in your application. Present it to the examining physician and include it with your Rally License Application. Attach additional pages if needed for any positive answers or conditions not listed below.

Name: ______Gender:_____ Age: ______Date of Birth: ______Address: ______City, State, Zip:______Phone: (Home) (_____ )______(Work) (_____)______E-mail______RA License #:______Years as licensed racer: ______Occupation:______Your Personal Physician: ______Address: ______City, State, Zip: ______Phone:( ____) ______

Date of Last Tetnus Booster:______Blood Type (if known): ______List all Medications, herbals, supplements being taken: ______List all adverse drug reactions or allergies: ______List all Medical Treatment with in the past 5 years and give name and address of physician consulted. ______

Have you been treated for, have you ever had, or have now, any of the conditions below? YES Condition NO Frequent or severe headaches; concussion or head injury; memory loss Epilepsy or seizures; dizziness / fainting (syncope); numbness or tingling in arms and hands or legs and feet Vision loss / eye problems (other than wearing glasses or contacts) Heart attack / coronary artery disease, angina, murmurs or valve disease, abnormal rhythms or bundle branch blocks, palpitations, high blood pressure, swelling in feet With mild exercise do you get fatigue, short of breath, wheezing, dizzy, weakness or pain in arms or legs? Asthma, COPD/Emphysema, other respiratory problems; Do you smoke tobacco? Diabetes, thyroid or other endocrine disease Blood or bleeding problems Hay fever, seasonal or environmental allergies Anxiety, depression, mental health problems; any alcohol or drug problems A history illness related to heat or cold exposure (heat stroke, frostbite etc) Amputations, Physical Disability, use special devices (joint brace, hearing aid etc.) Any broken bones, dislocated joints, swelling in muscles, joints or tendons Operations involving Eyes, Brain, Heart, Nerves, Blood vessels or Bones Previous denials/waivers for a racing license due to medical reasons Admission to a hospital with in the past 12 months Any automobile accident, including racing, in the past 2 years?

This is to certify that the above statements are true and accurate. I also give permission to any physician, hospital or institution, to furnish any information relative to my medical conditions to the Rally America Medical Board.

Applicant’s Signature: ______Date: M ____ D ____ Y ____ 2005 Rally America Physician’s Examination: To be completed by a Medical Doctor Page 3/3

Applicant’s Name: ______

Weight (Kg): Height (cm): Blood Pressure: Hair color: Eye color: Pulse:

Please attach an appropriate consultation report or explanation for any abnormal findings below. Normal Check appropriate column Abnormal Not Examined Skin (tattoos, rashes etc.) Head, neck, mouth Opthalmoscopic exam, pupils equal Neurological: Cranial Nerves, cerebellar testing, tendon reflexes, sensory exam, hearing etc. Pulmonary: Lungs / Thorax Cardiac: Size, rhythm, sounds (add written ECG report prn) Upper and Lower extremity Pulses Abdomen / viscera Upper & Lower extremities (strength and range of motion) Musculoskeletal / Spine (strength and range of motion) G – U system (rectal exam and stool heme card result) Psychiatric (specify any issues)

Vision: Right Eye Uncorrected 20/ ______Right Eye Corrected to 20/ ______Left Eye Uncorrected 20/ ______Left Eye Corrected to 20/ ______Both Eyes Uncorrected 20/ ______Both Eyes Corrected to 20/ ______Field of Vision (degrees from median): Right Eye ______Left Eye ______Color Vision (test used): ______Normal (check one) YES ____ NO____

Examining Physicians Comments on History and Examination: (use extra pages as needed) ______

The applicant should have no established medical history or clinical diagnosis that may reasonably be expected, within 12 months after this finding to make him/her be unable to perform as described on Page One while holding a Rally America Rally License.

Re-examination: It shall be the applicant’s responsibility to present for re-examination as follows: 1. Upon expiration of their current medical examination form; 2. Following a racing incident requiring hospital evaluation or admission; 3. Following any significant illness, injury or hospitalization

After careful consideration of the information provided to me and the above report, I make this recommendation: (Check One) ____ That the applicant IS physically and psychologically fit to drive a rally vehicle at high speeds in competition events. ____ That the Rally America Medical Advisory Board reviews this application and examination report.

Signed: ______Date: M____ D ____ Y ____

Examining Physician Printed Name:______Address: ______City, State, Zip: ______Phone: (____)______