Adventure Booking

Adventure Details

Personal Details

Home Address

Passport Details

Student?

Next of Kin Details

Please complete this medical questionnaire as accurately as possible. Your answers will be kept with the strictest of confidences and we will only use this information to ensure you're able to participate in a rigorous outdoor event and to call upon the information should you need medical treatment.

We reserve the right to refuse participation on medical grounds for yours and the groups' safety. Any decision made will be in consultation with you and your GP and should your medical details change after registration please inform us immediately.

Do you suffer or have you ever suffered from:

Respiratory and circulatory
Heart trouble and/or blood pressure problems	Yes No
Asthma, bronchitis and/or shortness of breath	Yes No
Diabetes	Yes No

Mobility
Fractures, tendon, ligament/cartilage damage	Yes No
Physical or other disability	Yes No
Severe head injury	Yes No
Back problems	Yes No
Altitude Sickness	Yes No
Are you registered disabled	Yes No
Vertigo	Yes No

Mental Health
Epilepsy and/or fainting episodes	Yes No
Migraine	Yes No
Psychiatric or mental illness	Yes No
Do you suffer from substance or alcohol abuse	Yes No

Other
Allergies	Yes No
Have you attended hospital for any investigations/treatments in the last 2 years	Yes No
Are you suffering from or a carrier of any infectious diseases	Yes No
Are you pregnant	Yes No
Do you suffer from any other conditions not listed above	Yes No

If you have answered yes to any of the above then please take this opportunity to list the details of your conditions.

If you have answered yes to ever suffering from Asthma please give details:
When was the last time you needed hospital treatment?

When was the last time you needed steroid tables?

What medication/inhalers do you use?

Do you currently use any form of medication regularly? If yes please provide details:

If you have answered yes to any of the above please download the medical form that needs to be completed by your GP or family doctor who has access to your medical files to confirm your place: Doctor's note (downloadable form).

Do you have any dietary needs that we need to be aware of?