Volunteer Medical Questionnaire

Your answers will be treated in the strictest confidence and will not necessarily adversely affect your chance to take part. We will attempt to accommodate everyone but reserve the right to refuse entry on medical grounds if we feel your safety and that of the group may be compromised.

 

Any decisions will be made in consultation with you. Incomplete information may delay your registration.

 

Should any of your medical details change after you have completed this form and before the departure date you must inform us. Failure to do so may invalidate your personal insurance.

Do you suffer or have you ever suffered from:

a) Heart trouble and/or blood pressure or circulatory problems?
b) Allergies?
c) Bronchitis and/or shortness of breath?
d) Fractures, Tendon, Ligament/Cartilage damage?
e) Diabetes?
f) Physical or other disability?
g) Epilepsy and/or fainting attacks?
h) Psychiatric or mental illness?
i) Migraine?
j) Have you been hospitalised within the last 2 years?
k) Severe head injury?
l) Are you suffering from or a carrier of any infectious diseases?
m) Back and/or joint problems?
n) Are you registered disabled?
Have you ever suffered from asthma?
Have you undergone surgery in the last 12 months, or are you due to have surgery?
Do you currently use any form of medication regularly?

Next of Kin Details

GP Details

In the event of an accident or illness whilst on the project, I hereby give Permission for the Project Manager, Medical or other Expedition staff to initiate medical treatment and to inform my next of kin in case of hospitalisation.

 

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To the best of my knowledge and belief this is a true and accurate description of any medical history and current conditions.

Thanks for submitting!