South African Boxing Act, 2001 (Act No. 11 of 2001)

Regulations

Purchase

ANNEXURE F

[Regulation 3(1)(d)]

MEDICAL EXAMINATION

(Indicated with X)

1.	Name______________Date of birth____________Height______Weight_________

2.	Educational standard attained___________________________________________

3.	Gender:______________________

Previous record:	Number of fights	_____________________
	Number of defeats	_____________________
	Number of knock-outs sustained by boxer	_____________________

5.	Any history of fits, seizures, convulsions, epilepsy__________________	Yes	No
6.	Any history of mental illness_____________________________________	Yes	No
7.	Any history of eye problems, relating to vision of otherwise_________	Yes	No
	Any history of previous illness or injury___________________________	Yes	No

OTHER NEUROLOGICAL SIGNS

PULSE/min__________________________

If any findings is abnormal please give details:



Doctor's name_____________________________________________	Signature________________________________________________
Address__________________________________________________	Qualifications____________________________________________
_________________________________________________________	Date of examination______________________________________

I. the undersigned, ___________________________________do hereby confirm that the

information herein before recorded and supplied by me is in all respects true and correct.

_____________________________

Boxer

As witnesses

1.______________________________________

2.______________________________________

Note: Indicate with an X in the appropriate block