Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
D.O.B
*
Next of kin details:
*
First Name
Last Name
Relationship to you
*
Phone
(###)
###
####
Email
Previous travel experience, in brief:
*
First aid experience
If medic please provide details
Do you have any medical concerns that you would like to raise with the medical team (in confidence) prior to the trip?
*
If ‘Yes’, you can either write your concerns below or leave it blank and we will contact you. Please feel free to approach us at any time independent of your response here with updated information or concerns.
Have you ever had lung/respiratory problems (e.g. asthma, COPD, pneumonia, TB, pulmonary embolism (PE), lung surgery, collapsed lungs)?
*
If yes please provide details here
*
Have you ever had heart/cardiac/blood vessel problems (e.g. high blood pressure, angina, heart attack, deep vein thrombosis (DVT), heart surgery)?
If ‘Yes’, please provide details here:
Have you ever had abdominal/bowel problems (e.g. hernias, stomach ulcers, reflux, inflammatory bowel disease, abdominal surgery, constipation, diarrhoea)?
If ‘Yes’, please provide details here:
Have you ever had brain/nerve problems (e.g. epilepsy, seizure, severe headaches, migraines, sciatica, carpel tunnel syndrome, reduced sensation, brain surgery)?
If ‘Yes’, please provide details here:
Have you ever had kidney/urinary/liver problems (e.g. recurrent cystitis, renal failure, liver failure, jaundice, hepatitis, pyelonephritis)?
If ‘Yes’, please provide details here:
Have you ever had hormone/endocrine problems (e.g. diabetes, thyroid problems)?
If ‘Yes’, please provide details here:
Have you ever had hormone/endocrine problems (e.g. diabetes, thyroid problems)?
If ‘Yes’, please provide details here:
Have you ever had psychiatric/psychological problems (e.g. depression, schizophrenia, bipolar disorder, psychosis, overdose, self-harm, eating disorder)?
If ‘Yes’, please provide details here:
Have you ever had altitude problems (e.g. acute mountain sickness (AMS), high altitude cerebral oedema (HACE), high altitude pulmonary oedema (HAPE))?
If ‘Yes’, please provide details here:
Have you ever had cold related problems (e.g. frostbite, Raynaud’s syndrome/very cold hands and feet, cold-induced asthma, chilblains, immersion/trench foot, hypothermia)?
If ‘Yes’, please provide details here:
Have you ever had heat related problems (e.g. heat exhaustion, heat stroke, sun stroke)?
If ‘Yes’, please provide details here:
Are you currently seeking specialist advice or treatment for any medical conditions?
If ‘Yes’, please provide details:
Have you ever suffered from a medical condition that you have not mentioned above requiring admission to hospital, long-term treatment or surgery?
If ‘Yes’, please provide details:
Have you had a dental check-up in the last year?
Do you have any ongoing dental problems?
If ‘Yes’, please provide details:
What is your blood group (if known)?
Have you ever had a blood transfusion?
If ‘Yes’, please provide details:
Do you have any form of physical or mental impairment or disability not mentioned above?
If ‘Yes’, please provide details:
Altitude experience (if going on a mountaineering expedition): What is the highest altitude over 3,000m (10,000ft) that you have been to?
How many times have you been over 3,000m (10,000ft)?
Are you currently taking any medications regularly (please including oral contraceptive, over-the-counter medications, inhalers, creams and herbal remedies*)?
Always travel with an extra course of these medications to replace lost or damaged supplies.
If ‘Yes’, please list the medication’s name, dose and how often it is taken:
Have you ever had an allergic reaction to any medication?
If ‘Yes’, please list the medication’s name and describe the symptoms/treatment of the reaction:
Have you ever had an allergic reaction to foods or environmental triggers (e.g. cats)?
If ‘Yes’, please provide details here:
Immunisations (with dates): * *Please note it is the expedition members’ responsibility to ensure recommended immunisations are up to date.
Diphtheria
Polio
Tetanus
Hepatitis A
Hepatitis B
Meningococcal meningitis
Rabies
Japanese encephalitis
Tuberculosis (BCG)
Typhoid
Yellow fever
Other:
Do you suffer from vertigo / fear of heights / motion sickness?
If ‘Yes’, please provide details:
Do you have any special dietary needs?
If ‘Yes’, please provide details:
Do you wear contact lense
Are you pregnant or might be at the time of travel?
If ‘Yes’, please provide details:
Are you a smoker:
Declaration
*
• I agree that the above information is true and accurate to the best of my knowledge.
• As far as I am aware I am medically fit to partake in a remote expedition which will be both physically and mentally demanding and potentially include exposure to extremes of heat, cold
and altitude.
• I understand that I am responsible for providing all my normal medications and supplies for the treatment of my pre-existing medical conditions for the duration of the expedition.
• I understand that my medical information will be kept confidential and every effort will be made to consult me beforehand should any disclosures be deemed necessary.
• I agree that should I become incapable of giving consent for disclosure of essential medical information in the event of an emergency, information may be imparted at the discretion of the
expedition team acting in my best interests.
• On return from the expedition, I consent to my GP being contacted with details of any serious illness or accident arising during the expedition.
• I agree to discuss/disclose to the organisers any injury or illness occurring between this date and the date of departure.
• I have made a copy of this completed form for my personal records.
