Please submit this form at least two weeks prior to the trip start date.
I ask for this information so that I’ll know in advance of special medical conditions you may have, rather than learning about them in a crisis. Also, in the event of a serious injury or illness, this form provides emergency medical personnel with a useful medical history.
This form is confidential. It will be seen only by myself, my assistant, medical personnel, or others who know and understand its confidential nature. The form will be retained for a period of time following the trip, after which it will be permanently deleted. If you choose not to go on the trip, this form will be deleted immediately.
Please contact me if you have any questions regarding the information on this form.
If this person is unavailable, please notify:
We strongly encourage you to have medical insurance and to bring you insurance card or other documentation.
ALLERGIESInclude medicine, foods, animals, insect bites/stings, environment (dust, pollen, etc.)
Please list all prescription, over the counter, and natural medications you are taking.
This trip may include vigorous activity, extended hiking, and other physically and mentally demanding exertion in isolated areas without immediate access to medical facilities, medical providers, or means of contacting rescue or medical personnel.