Medical Questionnaire - CONFIDENTIAL

PLEASE USE OUR 2008 MEDICAL FORM - CLICK HERE!

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

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

Members Name:

Proposed Expedition/Course: Taster Weekend India Bulgaria Norway Morocco Romania Scotland Cairngorm Scotland Mull D of E Gold Expedition Medicine

Have you been investigated or treated by a consultant for any illness, physical or mental in the last five years? YES/NO Yes No If so give details

Do you suffer from any disability that could affect your performance on the expedition/course? YES/NO Yes No
If so give details

Do you take or have you been advised to take any treatment regularly? Yes No
If so please give details (drug name and dose):

Do you react adversely to any medication or medical treatment?

Aspirin Yes No Penicillin Yes No
Zinc Oxide plaster (“Elastoplast” etc.) Yes No
Other; please specify:

Do you have to avoid any food, household products, toiletries, insects, plants or animals because of allergy intolerance? Yes No If so give details

Do you suffer with any condition which affects your mobility, strength or fitness? Yes No If so give details

Do you anticipate any changes in your medical condition/fitness before the expedition/course (e.g. planned changes; medication, operations etc.) Yes No If so give details

Please add here any other information concerning your health and your participation on the expedition/course which has not been covered by the above questions.

I declare that the information given above is to the best of my knowledge and belief correct and complete.

If you are under 18 years of age, your parent or guardian must sign here; ___________________

PLEASE BE AWARE THAT IF YOU ARE APPLYING FOR AN OVERSEAS EXPEDITION, A 'CERTIFICATE OF
FITNESS' MAY BE REQUIRED FROM YOUR DOCTOR. YOU WILL BE ADVISED IF THIS IS NECESSARY.

If there is not enough room in any of the boxes you must submit a seperate sheet with your details

Please print this form out, sign it and return it with your completed application form