Fillable Printable Non-NASA Medical Declaration Form
Fillable Printable Non-NASA Medical Declaration Form
Non-NASA Medical Declaration Form
Revised 2/15 Previous versions are obsolete
Page 1 of 2
Non-NASA Medical Declaration Form
Applicant: Use this Form ONLY if you are submitting a Racing Medical/Physical Exam Form from another racing
organization for purposes of obtaining a NASA Competition Race License. Complete this page legibly and in its
entirety. Failure to complete the information will delay processing of your license. The examining physician must
be an M.D. or D.O. Any physical examination by a P.A. or N.P. must be co-signed by a supervising physician. All
drivers that are age 40 or older must submit a copy of a 12-lead EKG with this form as a baseline (unless NASA
already has one on file from a previous submission.) All Non-NASA Medicals will be reviewed, and are subject to
request for a new medical evaluation, using the standard NASA Medical Evaluation Form.
Note- the answer of “yes” for any condition highlighted below MUST have a comment on page 2, and
may be cause for review and requests for further evaluation/testing by the NASA Medical Director.
Name:_________________________________ Member #: _______ Age:____ Date of Birth:__________
Address:_______________________________________ City, St, Zip:___________________________
Email Address: __________________________________ Occupation:___________________________
Phone: (H) ______________________ (W) ______________________ (C)_______________________
Personal Physician: ______________________________________ Phone:_______________________
Address: ______________________________________ City, St, Zip:____________________________
Examining Physician: _____________________________________ Phone:_______________________
Address: ______________________________________ City, St, Zip:____________________________
P
LEASE INDICATE IF YOU EVER HAD
,
OR HAVE NOW
,
ANY OF THE FOLLOWING
:
Do You Have or Have You Ever Had? Yes No Do You Have or Have You Ever Had? Yes No
1. Frequent or severe headaches
14. Any drug, narcotic, or alcohol problems
2. Unconsciousness for any reason
15. Psychiatric/mental health problems
3. Dizziness or fainting spells
16. Eye trouble (except glasses)
4. Epilepsy or seizures
17. Asthma, COPD or other pulmonary problem
5. Coronary artery disease or angina
18. Diabetes
6. Heart valve Problems
19. Anemia or other blood diseases including abnormal
bleeding
7. Left bundle branch block (heart)
20. Admission to a hospital in the past 12 months for
any reason
8. Abnormal cardiac rhythms/ Pacer/ AICD
21. Allergy(s) to medications List:
9. High blood pressure
22. Routine use of Pain Medication
10. Operation(s) on brain
23. Amputations/physical disability
11. Operation(s) on heart
24. Illness(es) not listed above List:
12. Operation(s) on eyes, nerves, blood
vessels, or bone
25.
Blood Thinner Medication
of any kind
13. Previous waiver(s) from NASA, SCCA,
BMWCCA, PCA or other sanctioning
body for medical condition(s)
26. Previous denial(s) from NASA, SCCA, BMWCCA,
PCA, or other sanctioning body due to medical reasons
Date of last Tetanus
________________
Blood Type
_________
Medications Used (including eye drops and OTC Meds): ______________________________________________________
___________________________________________________________________________________________________
Revised 2/15 Previous versions are obsolete
Page 2 of 2
Non-NASA Medical Declaration Form—Page 2
Have you had an automobile accident, including racing, in the past two (2) years? If “yes”, please
explain all injuries sustained, and the basic circumstances of the incident:
_______________________________________________________________________________
_______________________________________________________________________________
Additional History or Comments:
(Place comments to all “Yes” answers from Page 1 here)
Renewal Intervals (minimum intervals without abnormalities):
*Exceptions: Medical clearance may be granted in certain circumstances with the approval of the NASA Medical
Director. NASA will stipulate any additional requirements or modified/shortened renewal intervals.
Applicants that are less than 40 years old must renew their Medical Evaluation every five years.
Applicants that are at least 40 years old must renew their Medical Evaluation every three years.
Applicants that are at least 50 years old must renew their Medical Evaluation every two years.
Applicants that are at least 70 years old must renew their Medical Evaluation every 12 months.
I certify that the above is true and correct information. I give my permission for the NASA administration to access
and/or exchange information with any health care providers or institutions as well as the medical administration of
other sanctioning bodies. I will immediately notify NASA if there is any change in my medical condition .
Affirmed:
_______________________________ _________
Applicant Signature Date
