Medical History Form

Date*

Name*

First Last

Email*

Date of Birth*

Height*

Weight*

Sex*

Rescue / Evacuation Insurance Provider(s)

Policy #s: Rescue / Evacuation Insurance Provider(s)

Travel Insurance Provider

Policy #s: Travel Insurance Provider

Medical Emergency Contact*

First Last

Medical Emergency Contact Phone*

Medical Emergency Contact Email*

Enter Email Confirm Email

How far can you run/jog without distress?*

1 mile
3 miles
5 miles
more

How long can you walk with a daypack?*

4 hours
8 hours
12 hours
more

What is the heaviest pack you've carried and for how long?*

What is the highest altitude you've reached? Where?*

Describe your current exercise activities including frequency, time and distance.*

Alcohol frequency*

Tobacco use*

Currently
Formerly
N/A

Current medications*

Blood type*

Allergies*

Hospitalized in the past 2 years?*

Operations/ procedures in last 12 months*

Sicknesses or injuries in last 12 months*

Dietary Requirements, Allergies, Intolerances*

Drug Intolerance(s)*

Any history of:

Explain any medical history*

I am current with all recommended and basic immunizations*

Yes
No
I don't know

Have you been in a tropical country in the past 2 years, especially one where malaria is prevalent?*

Have you ever suffered symptoms of Acute Mountain Sickness (AMS), High Altitude Cerebral Oedema (HACE) or High Altitude Pulmonary Oedema (HAPE)?*

This activity may involve extreme physical and psychological challenges. By signing this form you confirm you are aware of this and that you are fit and able to undertake this activity and are NOT participating against the advice of your doctor. In the event of an accident or illness on the trip, I hereby give permission for the activity leader, doctor, or whoever is in charge of the expedition at the time to initiate medical treatment and inform my next of kin in the event of hospitalization if deemed necessary. To the best of my knowledge, this is a true and accurate description of my medical history and current condition. I will inform the Volant, LLC and my travel insurance company of any change in my medical condition, including pregnancy, which may arise between now and the date of departure. I agree to inform the Volant, LLC and/or the expedition leader of any reason, medical or otherwise, that may affect my ability to participate in this activity.*

I understand and confirm my awareness
I do not understand and do not confirm my awareness

Signature*

Medical History Form

Personal Contact Information

Liability Release Form

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