Aconcagua booking form

    PERSONAL INFORMATION:

    Gender:
    Type of ID:

    ADDRESS INFORMATION:

    EMERGENCY INFORMATION:

    In case of Emergency contact (please ensure the person speaks English):

    Relationship:

    Diet Information:

    Type of Diet:
    Health Condition:

    Medical Information:

    Blood Type:

    Have you ever suffered from any of these conditions?

    Hypertension:
    Allergies:
    Diabetes:
    Smoking:
    Breathing problems:
    Cardiac condition:
    Seizures:
    Pregnancy:
    Do you take any medicine?
    Spine problems:
    Previous luxations:
    Do you wear glasses?:
    Have you ever had AMS (Acute Mountain Sickness)?:
    Have you ever had HAPE (High Altitude Pulmonary Edema)?:
    Have you ever had HACE (High Altitude Cerebral Edema)?:
    Are you under medical supervision?:
    How would you describe your general health?:

    Mountaineering experience: