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: