As part of your registration for a this program you need to complete and
submit this form.
Program name and date
This is, in part, to help you assess your own level of health, but also to
provide us with information on your health. If you have had or are currently experiencing
any of the following conditions:
1) Tick the box and give details in the box at the bottom. Be specific,
include: dates, names of medication, history of condition, current status,
2) Check with your physician about your fitness to undertake a physically active
1. Problems with vision or
hearing -- requiring glasses, contact lenses or hearing aid.
2. Dizzy spells, fainting, convulsions,
3. Frequent infection of throat,
tonsils, sinuses, ear.
4. Chronic cough, bronchitis, bloody
5. Shortness of breath, or asthma on
6. Chest pains on exertion or deep
7. Palpitation of the heart, irregular
heart beat, heart murmurs, or poor circulation.
8. Low or high blood pressure.
9. Frequent nausea or vomiting, food
10. Jaundice or hepatitis.
11. Frequent diarrhea or blood in the
12. Frequent abdominal cramps,
severe menstrual cramps.
13. Hernia, lifting restrictions.
14. Difficulty urination, burning
or pain on urination, frequency in urinating.
15. Kidney infection or stones.
16. Chronic pain in neck, back,
shoulders, arms or legs.
17. Broken bones, joint dislocation,
serious sprains, weakness of muscles.
18. Joint pains, swelling or stiffness
19. Any severe injury to head,
chest, internal organs.
20. Severe illness requiring
hospitalization or prolonged incapacitation.
21. Chronic skin problems (rash
22. Reaction to extremes of
temperature, heat exhaustion, sunstroke, frostbite, impaired circulation.
23. Claustrophobia, agoraphobia,
acrophobia (strong fear of confined places, open areas, or heights.)
24. Abuse of alcohol, drugs,
25. Episodes of depression, anxiety,
26. History of diabetes,
thyroid trouble, bleeding problems.
28. Had or presently have a
29. Are you under treatment of a
psychologist or psychiatrist?
30. Currently on any medication.
If so, what?
31. Allergic to any;
food(s), drug(s), animal(s), other
32. Special dietary restrictions (i.e.
vegetarian, macrobiotic, etc.)
33. Any medical
conditions, allergies, sun sensitivity or dietary restrictions which might
cause difficulties or need special attention during the trip.
Additional Information (give reference number):
MEDICAL INSURANCE COVERAGE:
Policy or certificate number: #
Does it provide world-wide, 24-hour coverage: Yes No
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