Medical Form

EXPEDITION DATE (important) __________________________________

E-mail address: __________________________________

This form does not need to be completed by a doctor. The information is important,

so please answer all questions carefully and return the completed form to Earth River

Expeditions as soon as possible.

NAME__________________________________________________________________

HEIGHT______WEIGHT________GENDER_______DATE OF BIRTH____________

PASSPORT #_____________________________________ COUNTRY_____________

EMAIL ADDRESS_________________________________________

IN CASE OF EMERGENCY CONTACT: NAME_______________________________

RELATIONSHIP____________

ADDRESS______________________________________________________________

DAY PHONE______________________________ EVENING____________________

LIST ALL MEDICATIONS CURRENTLY BEING TAKEN AND WHY: ___________

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LIST ALL ALLERGIES___________________________________________________

IS THERE A HISTORY OF ALLERGIES TO INSECT STINGS IN YOUR FAMILY?

________ IF YES, WHO AND WHICH INSECT_______________________________

IF YOU ARE ALLERGIC, WILL YOU HAVE MEDICATION WITH YOU?________

DATE OF MOST RECENT TETANUS SHOT_________________________________

HAVE YOU EVER SUFFERED FROM: (answer Y or N)

ANEMIA____________ EPILEPSY___________ DIZZINESS__________

CHEST PAIN_________ APPENDECTOMY________ KIDNEY AILMENT_______

SEVERE INFECTION________ SEVERE MENSTRUAL CRAMPS__________

JOINT INJURY/DISEASE_______ HEAD INJURY W/ UNCONSCIOUSNESS______

DO YOU WEAR CONTACT LENSES? ________________________

BONE INJURY_________ FAINTING_____________ BACK PROBLEMS_________

DIABETES___________ DIGESTIVE PROBLEMS__________ HERNIA_________

ARE YOU A VEGETARIAN? ___________________________________________

LIST ANY DIETARY RESTRICTIONS/ PREFERENCES________________________

ARE YOU A SMOKER __________________________________________________

PLEASE ELABORATE ON THE ABOVE OR ANY OTHER MEDICAL PROBLEMS

(INCLUDE DATES AND CURRENT CONDITION)

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PLEASE EXPLAIN YOUR CURRENT EXERCISE ROUTINE, IF ANY:____________

(Please elaborate)