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Expedition Booking Details

Please fill in the expedition booking details form below to provide us with your personal and medical details for a booking.

Your privacy is important to us, we need this information for your safety and comfort. Please see our Privacy and Cookie Policy for more information. Please read the Expedition Booking Conditions before completing your form.

PERSONAL DETAILS

Full Name

Address

Email

Telephone

Mobile

D.O.B

Activity you have booked with us

Activity Start and End Dates

Please outline any experience you have?

PASSPORT DETAILS

Name on Passport

Passport Number

Passport expiry date

Issuing authority

Nationality

 

INSURANCE

Insurance Company

Policy Number

24 hour emergency number

 

NEXT OF KIN

Name

Relationship to you

Contact Email

Contact Number

 

GP DETAILS

Name

Phone Number

Address

FIRST AID EXPERIENCE

Please tick your experience level

NoneBasicIntermediateQualified Medic

If qualified medic please provide details

MEDICAL DISCLOSURE - GENERAL

Please rate your physical condition

PoorFairGoodExcellent

Please select your swimming ability

Can't SwimNoviceIntermediateAdvanced

Do you have any medical conditions you wish to disclose (in confidence) to Exped Adventure?

YesNo

If YES please provide details

 

Have you ever had any lung/respiratory problems (e.g. asthma, COPD, pneumonia,TB, pulmonary embolism (PE), lung surgery, pneumothorax)?

YesNo

If YES please provide details

 

Have you ever had any heart/cardiac/blood vessel problems (e.g. high blood pressure, angina, heart attack, deep vein thrombosis (DVT), heart surgery)?

YesNo

If YES please provide details

 

Have you ever had any abdominal/bowel problems (e.g. hernias, stomach ulcers, reflux, inflammatory bowel disease, abdominal surgery, constipation, diarrhoea)?

YesNo

If YES please provide details

 

Have you ever had any brain/nerve problems (e.g. epilepsy, seizure, severe headaches, migraines, sciatica, carpel tunnel syndrome, reduced sensation, brain surgery)?

YesNo

If YES please provide details

 

Have you ever had any kidney/urinary/liver problems (e.g. recurrent cystitis, renal failure, liver failure, jaundice, hepatitis, pyelonephritis)?

YesNo

If YES please provide details

 

Have you ever had any hormone/endocrine problems (e.g. diabetes, thyroid problems)?

YesNo

If YES please provide details

 

Have you ever had any psychiatric/psychological problems (e.g. depression, schizophrenia, bipolar disorder, psychosis, drug overdose, self-harm, eating disorder, alcohol dependency)?

YesNo

If YES please provide details

 

Are you currently seeking specialist advice or treatment for any medical conditions?

YesNo

If YES please provide details

 

MEDICAL DISCLOSURE - ALTITUDE & TEMPERATURE

Have you ever had any heat related problems (e.g. heat exhaustion, heat stroke, extreme sunburn )?

YesNo

If YES please provide details

 

Have you ever had any cold related problems (e.g. frostbite, Raynaud's syndrome/very cold hands and feet, cold induced asthma, chilblains, immersion/trench foot, hypothermia)?

YesNo

If YES please provide details

 

Have you ever had any altitude problems (e.g. acute mountain sickness (AMS), high altitude pulmonary oedema (HAPE), high altitude cerebral oedema (HACE))?

YesNo

If YES please provide details

 

What is it highest altitude above 3000m (10,000ft) that you have been to before?

 

How many times have you been over 3000m (10,000ft)?

 

MEDICAL DISCLOSURE - DENTAL & OPTICAL

Have you had a dental check-up in the last year?

YesNo

Did you have to have any procedures?

YesNo

If YES please provide details

 

Do you have any on-going dental problems?

YesNo

If YES please provide details

 

Do you wear contact lenses?

YesNo

Have you had laser eye surgery?

YesNo

If YES, what type?

 

MEDICAL DISCLOSURE - MISC

What is your blood group (if known)?

 

Have you ever had a blood transfusion?

YesNo

If YES, please provide details

 

Do you have suffer from vertigo/motion sickness/ fear of heights?

YesNo

If YES, please provide details

 

Are you pregnant or might be at the time of travel?

YesNo

If YES, please provide details

 

Are you a smoker?

YesNo

Do you have any special dietary requirements?

YesNo

If YES, please provide details

 

MEDICAL DISCLOSURE - MEDICATION & IMMUNISATIONS

Are you currently taking any medications regularly (including oral contraceptive, over-the-counter medications, inhalers, creams and herbal remedies)?

YesNo

If YES, please list the medications name, dosage, and how often it's taken

 

Have you ever had an allergic reaction to any medication?

YesNo

If YES, please list the medications name and describe symptoms/treatment of reaction

 

Have you ever had any allergic reactions to foods (e.g. peanuts, shellfish, eggs) or environmental triggers (e.g. cats, dogs, horses)?

YesNo

If YES, please provide details, medication and symptoms (if applicable)

 

Please provide DATES of the following immunisations (n.b. it is the expedition members' responsibility to ensure recommended immunisations are up to date)

Diptheria

 

Polio

 

Tetanus

 

Hepatitis A

 

Hepatitis B

 

Meningococcal meningitis

 

Rabies

 

Japanese encephalitis

 

Tuberculosis(BCG)

 

Typhoid

 

Yellow fever

 

Other - please give names and dates

Please give the name of anti-malaria medication if applicable

 

MEDICAL DISCLOSURE - ADDITONAL

Have you ever suffered from a medical condition that you have not mentioned above requiring admission to hospital, long-term treatment or surgery?

YesNo

If YES, please provide details

 

Do you have any form of physical or mental impairment or disability not mentioned above?

YesNo

If YES, please provide details

 

DECLARATIONS

• I have read the Expedition, Challenge, Trek or Course description and the booking conditions and I accept these booking conditions in full. I am aware that participation in adventurous activities entails some risk of injury. Exped Adventure staff are trained, insured and qualified to run activities, however, participants accept that accidents and injuries may occur. By submitting this form you also understand it is your responsibility to organise appropriate insurance cover for this booking.

• I agree that the above information is true and accurate to the best of my knowledge.

• As far as I am aware I am medically fit to partake in a remote expedition which will be both physically and mentally demanding and potentially include exposure to extremes of heat, cold and altitude.

• I understand that I am responsible for providing all my normal medications and supplies for the treatment of my pre-existing medical conditions for the duration of the expedition.

• I understand that my medical information will be kept confidential and every effort will be made to consult me beforehand should any disclosures be deemed necessary.

• I agree that should I become incapable of giving consent for disclosure of essential medical information in the event of an emergency, information may be imparted at the discretion of the medical team acting in my best interests.

• On return from my expedition, I consent to my GP being contacted with details of any serious illness or accident arising during the expedition.

• I agree to discuss/disclose to the organisers any injury or illness occurring between this date and the date of departure.

YesNo

Name

Date

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