Personal Medical History

 

The Doctor Will Be In Momentarily ... Now Turn Your Head And Cough

 

 

Important Notice: Fill out this form honestly and completely. The information you provide will be held in strict confidentiality and will be released only to medical professionals in the event you are injured and require medical care. In the event you are abducted by aliens and rectal-probed all bets are off and we'll sell it to the highest bidder.

 

General Information

Name

               First

            Middle

               Last                                                             

 

Address

 Street Address

                City

  State/Province

Zip/Postal Code

           Country

 

Insurance Information

I do   do not have a general medical insurance policy currently in effect.

          Provider

        Policy No.

        Group No.

 

Medical History

   Date of Birth

            Height

           Weight

      Blood Type

                Sex Male   Female

 

Food/Drug allergies

 

 

 

Have you been seriously ill or injured in the past year?

Yes   No

If yes, please explain

 

 

 

Have you been hospitalized or had surgery in the past two years?

Yes   No

If yes, please explain

 

 

 

Do you wear contact lenses? Yes   No

Have you had your vision surgically corrected?Yes   No

If yes, what type of procedure (Lasik, RK, etc.) and what date?

 

 

 

Do you use alcohol?  Yes   No

If yes, how often and how much?

 

 

 

Do you use tobacco?  Yes   No

 

Please list all current medications and the conditions for which you take them.

 

 

 

Please list all dietary/performance supplements you currently take.

 

 

 

Do you carry an inhaler or injectable epinephrine?Yes   No

 

Do you have a history of any of the following medical conditions? (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you checked any of the above, please explain. Include date of last episode, duration, severity, current symptoms and limitations.

 

 

 

Is there any other pertinent health-related information about you we should be aware of?

 

 

 

Fitness Routine

Briefly describe your current fitness routine. Include type of exercise, weight, distance, frequency, duration, etc.

 

 

 

Emergency Contact

Name

               First

            Middle

               Last

  (Relationship)

 

Address

 Street Address

                City

  State/Province

Zip/Postal Code

           Country

 

Phone

              Home

              Work

                Cell

              email

 

Conditions of Expedition Medical Care

I understand that medical care as I know it is not available outside of my country of residence. I understand that I might be hours or days from any medical facility and that that medical facility to which I might be taken will not have the same standards of care as a similar facility in my country of residence, nor will the medical personnel treating me have the same training as medical personnel in my country of residence.

I understand that Expedition-Logistics does not provide any insurance, either medical, evacuation, liability, trip cancellation, or otherwise, for any incident which may arise as a result of my participation in any phase of this expedition. I agree to secure adequate trip cancellation, medical, evacuation, and other insurance as a condition to my participating in this expedition.

I hereby give my permission for transportation to any medical facility or hospital, and I authorize any qualified medical personnel to provide me with emergency medical care.

 

Electronic Signature

I adopt the mark typed in the form below as my electronic signature. By signing in the box below I  declare (or certify, verify, or state) pursuant to Title 28 U.S.C. §1746, under penalty of perjury under the laws of the United States of America, that the foregoing representations are true and correct.

 Enter your full name (E-sign):