Please complete this form to the best of your ability, as it is in the best interest of yourself, your fellow trip members, and your guides that all of the information provided is accurate and complete. Completion of this form is mandatory for trip participation and must be returned to our office at least 30 days prior to departure. Your answers are for our records only and will be considered confidential.

Participant's Name:____________________________________________Date:________________________
Trip Name:_______________________________________________Trip Date:_______________________
Date of Birth:______________________Sex:_____Height:___________Weight:________________________
In case of emergency call:______________________________________Phone:________________________
Name of your physician:_______________________________________Phone:________________________
Medical Insurance Provider:_________________________________________________________________
Identification Number:_____________________________________________________________________
Evaluate your health: Fair______________Good_______________Excellent___________________________
Evaluate your physical condition: Below average___Average____Above average____Excellent______________
Evaluate your swimming ability: Poor_______Fair_________Good_________Excellent___________________
Date of your last tetanus inoculation:___________________________________________________________
(Note: For all trips, it is mandatory that you have a tetanus shot within the last ten years.)
Has there been any change in your general health the past year? YES NO
If so, please explain_______________________________________________________________________
Are you now under the care of a physician? YES NO
If so, what is the condition being treated?_______________________________________________________
Have you had a serious illness, injury, or operation? YES NO
If so, what was the illness, injury, or operation and date?____________________________________________
Have you been hospitalized or had a serious illness within the past five years? YES NO
If so, what was the nature of the illness and date?_________________________________________________
Do you wear contact lenses? YES NO
Any serious trouble associated with any previous dental treatment? YES NO
List any special dietary requirements or food allergies:______________________________________________

Do you have or have you had any of the following diseases or problems:
Allergies YES NO If so, to what:?____________________________________________________________
Arthritis YES NO
Asthma or hay fever? YES NO
Back problems YES NO
Cardiovascular disease: heart trouble, heart attack YES NO
Coronary insufficiency, stroke, coronary
occlusion,arteriosclerosis YES NO
Fainting spells or seizures YES NO
Hepatitis, jaundice or liver disease YES NO
High blood pressure YES NO
HIV YES NO
Hives or skin rash YES NO
Inflammatory rheumatism (painful swollen joints) YES NO
Kidney trouble YES NO
Knee problems YES NO
Low blood pressure YES NO
Tendonitis, Tenosinovitis, or Carpal-tunnel syndrome YES NO
If so, date and details_____________________________________________________________________
Shoulder problems YES NO
Abnormal bleeding associated with
extraction, surgery or trauma YES NO
Anemia or other blood disorder YES NO
Women: Are you pregnant? YES NO
Are you taking any of the following?
(Please print the drug name.)
Antibiotics or sulfa drugs YES NO___________________________________________________________
Anticoagulants (blood thinners) YES NO______________________________________________________
Antihistamines YES NO___________________________________________________________________
Anti-inflammatories YES NO_______________________________________________________________
Cortisone (steroids) YES NO_______________________________________________________________
Digitalis or drugs for heart condition YES NO __________________________________________________
Insulin YES NO
Nitroglycerin YES NO
Pain Killers YES NO ____________________________________________________________________
Other YES NO ________________________________________________________________________
Are you allergic or had a reaction to:
Anti-inflammatories YES NO
Aspirin YES NO
Barbiturates, sedatives, sleeping pills YES NO
Codeine or other narcotics YES NO
Iodine YES NO
Local anesthetics YES NO
Penicillin or other antibiotics YES NO
Sulfa drugs YES NO
Other YES NO
Do you have any disease, condition, or problem not listed above that you
think we should know about? If so, please explain._____________________________________________

____________________________________________________________________________________

Note to participants traveling outside Canada and the U.S.: Please check
with your local travel clinic for current inoculation requirements and other
health recommendations for your destination.

I am medically, physically, and in all other respects, fit and fully able to
participate in adventure travel and have no special medical requirements or
conditions except as noted above. Should there be any change(s) related to
my health or my ability to participate in the trip, I will notify the office
and/or guide immediately.

Signature___________________________________________Date____________________