Medical History Form

HEALTH HISTORY AND EMERGENCY CONTACT FORM:

This Participant Health History and Emergency Contact Form (hereafter “Form”) must be completed honestly, accurately, and completely by every Participant over the age of 18 or by the parent/guardian of a Participant under the age of 18. This information will only be shared as necessary with Infuse Travel staff, contracted partners, or others that will be directly responsible for ensuring the safety and wellbeing of the Participant and will remain protected and considered confidential to the best of our ability.

Completion and review of this health history information is required for each Participant before traveling and a core element of our health and safety system. Our ability to clearly understand pre-existing medical, physical, or mental health conditions allows us to address and potentially limit threats based on the remoteness of program locations, activities involved, and potential limitations available within the areas we visit. We strongly advocate that all Participants collaborate with their physician, therapist, or other personal care professionals about the specific program location, travel needs, and activities listed in the program itinerary while completing this form.
EMERGENCY CONTACT INFORMATION

(Please ensure at least one emergency contact is a proficient English speaker.)
First Name
Middle
Last Name
DateofBirth(DD/MM/YYYY):*

DayMonthYear
Participant Mobile Number
Email Address*
What is your gender?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PRIMARY EMERGENCY CONTACT #1
Name

First NameLast Name
Relationship to Participant
Home Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Email
State
Country
PRIMARY EMERGENCY CONTACT #2
Name

First NameLast Name
Relationship to Participant
Home Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Email
State
Country

MEDICAL CONTACT - Doctor
Name

First NameLast Name
Clinic
Work Phone
Please enter a valid phone number.
Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MEDICARE DETAILS
Medicare Number
Participants Position on the card
Expiry Date

DayMonthYear
Date

INSURANCE INFORMATION
Is the participant covered by travel insurance ?

YesNo
Name of Insurer / Provider:
Policy Number
Insurer's Emergency Assistance Phone Number
Please enter a valid phone number.
Please carry a copy of your insurance and prescription cards while on your program.
Is the participant covered by Private Health insurance ?

YesNo
Name of Insurer / Provider
Policy Number
Does the participant covered by Ambulance insurance ?

YesNo
Name of Insurer / Provider
Policy Number

ALLERGY AND MEDICATIONS

The following information must be completed honestly and accurately by the participant or the parent/guardian of a minor participant with the minor participant's assistance.

Known Allergies

Please list all known allergies (including but not limited to food [nuts, shellfish, and others], insects, plants, medications, etc.) and describe triggers, symptoms, and severity of reaction (including possible anaphylaxis).
Has Participant been prescribed epinephrine, such as an Epi-Pen for any allergies?

YesNo
If yes, please bring at least two epinephrine injections in addition to all other allergy medications as prescribed.
Please provide any Action Plans if applicable.
Allergy
Reaction Type or Description of Reaction Symptoms
Severity of Reaction
Treatment of Reaction
Do you want to add more allergy ?

YesNo
List additional allergies or notes in the Additional Information section at the end of this form.
Allergy 2
Reaction Type or Description of Reaction Symptoms
Severity of Reaction
Treatment of Reaction
Allergy 3
Reaction Type or Description of Reaction Symptoms
Severity of Reaction
Treatment of Reaction

Current Medications

Please list all prescription medications that the Participant will take while on the program (prescription AND over the counter). Remember to bring adequate quantities of medication(s) to last the entire duration of the program. Keep prescription drugs in original packaging that identifies the prescribing physician, the name of the medication, the dosage, and the frequency of administration. This is particularly important for entering into and transferring through international destinations. Please email any additional information that does not fit on this page.
Medication 1
Type of Medication
Reason for Medication
Dosage
Frequency of Dosage
Side Effects of Medication
Effects of Missed Dose
Do you want to add more Medication?

YesNo
Medication 2
Type of Medication
Reason for Medication
Dosage
Frequency of Dosage
Side Effects of Medication
Effects of Missed Dose
Medication 3
Type of Medication
Reason for Medication
Dosage
Frequency of Dosage
Side Effects of Medication
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