IRC 2015 Entry Form – Step 4 | WISA – Western India Sports Association

Particulars	Driver	Co-Driver
Diabetes	YesNo	YesNo
Family History	YesNo If yes, then MotherFatherBoth	YesNo If yes, then MotherFatherBoth

Hyper Tension	YesNo	YesNo
Family History	YesNo If yes, then MotherFatherBoth	YesNo If yes, then MotherFatherBoth

Cardiac Disease	YesNo	YesNo
Family History	YesNo If yes, then MotherFatherBoth	YesNo If yes, then MotherFatherBoth

Asthma	YesNo	YesNo
Family History	YesNo If yes, then MotherFatherBoth	YesNo If yes, then MotherFatherBoth

Epilepsy	YesNo	YesNo
Family History	YesNo If yes, then MotherFatherBoth	YesNo If yes, then MotherFatherBoth

Any drug Allergies	YesNo	YesNo
Please specify