Medical Questionnaire Form

Please complete in full, print, and sign.

Medical Questionnaire - CONFIDENTIAL

The information on this questionnaire will be seen by the Administrator and the expedition Leader and insome circumstances our Medical Advisor. Except as directed by your own doctor, no medical condition orhandicap will be an automatic bar to your joining a course or expedition, however it is important for theleader when planning the expedition that we know about such conditions which may adversely affect thesuccessful completion of its aims.

The questions have been designed to provide information helpful to the leader in any medical situation inwhich you may be involved. It is for this reason that you are required to complete this form fully and advisethe leader of any changes in your health or fitness between now and the start of the expedition/course.

Complete all compulsory fields, denoted by , any form errors will be listed below and the field will be prefixed with a icon

1. Forename:
2. Surname:
3. Proposed Expedition/Course:
4. Have you been investigated or treated by a consultant for any illness, physical or mental in the last five years?:
5. If so, give details:
6. Do you suffer from any disability that could affect your performance on the expedition/course?:
7. If so, give details:
8. Do you take or have you been advised to take an treatment regularly?:
9. If so, give details (drug name and dose):
10. Do you react adversely to any medication of medical treatment?
11. Aspirin:
12. Penicillin:
13. Zinc Oxide plaster("Elastoplast" etc.):
14. Other; please specify:
15. Do you have to avoid any food, household products, toiletries, insects, plants or animals because of allergy intolerance:
16. If so, give details:
17. Do you suffer with any condition which affects your mobility, strength or fitness:
18. If so, give details:
19. Do you anticipate any changes in your medical condition/fitness before the expedition/course (e.g. planned changes; medication; operations etc.):
20. If so, give details:
21. Please add here any other information concerning your health and your participation on the expedition/course which has not been covered by the above quesions:

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