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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.
D.O.B
Height
Weight
Do you suffer or have you ever suffered from:
a) Heart trouble and/or blood pressure or circulatory problems?
Yes
No
b) Allergies?
Yes
No
c) Bronchitis and/or shortness of breath?
Yes
No
d) Fractures, Tendon, Ligament/Cartilage damage?
Yes
No
e) Diabetes?
Yes
No
f) Physical or other disability?
Yes
No
g) Epilepsy and/or fainting attacks?
Yes
No
h) Psychiatric or mental illness?
Yes
No
i) Migraine?
Yes
No
j) Have you been hospitalised within the last 2 years?
Yes
No
k) Severe head injury?
Yes
No
l) Are you suffering from or a carrier of any infectious diseases?
Yes
No
m) Back and/or joint problems?
Yes
No
n) Are you registered disabled?
Yes
No
If you have answered yes to any of the above questions, or have any other medical conditions we should be aware of please give further details below:
Have you ever suffered from asthma?
Yes
No
Have you undergone surgery in the last 12 months, or are you due to have surgery?
Yes
No
If yes please give details:
Do you currently use any form of medication regularly?
Yes
No
If yes please give details:
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.
To the best of my knowledge and
belief
this is a true and accurate description of any medical history and current conditions.
I agree
I agree
Submit
Thanks for submitting!
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