MEDICAL RELEASE FORM
General Information:
We urge you to be completely thorough with the information requested in order to help us ensure a safe experience for each client. It is the intention of Pronatura A.C. Veracruz to take all reasonable precautions and minimize risks by having the client and his or her physician know the demands of the activities during the trip. We must be aware of all medical conditions that may present a problem during the trip. If there is any question concerning your physical condition, ability or history in health, we ask that you have a complete physical examination and provide us with a signed Medical History Statement from your physician. All information will remain confidential.
PERSONAL DATA (to be completed by participant)
TRIP DATES_______________________________________TRIP NAME__________________________________
NAME_____________________________________________________________ SEX: M[ ] F [ ]
ADDRESS______________________________________________________________________________________
CITY__________________________________STATE___________________ZIP CODE______________________
HOME PHONE__________________________________ WORK PHONE_________________________________
AGE_____________________BIRTHDATE___________________HEIGHT________________WEIGHT________
OCCUPATION__________________________________ EMAIL_________________________________________
FAMILY PHYSICIAN_______________________________________PHONE______________________________
ADDRESS______________________________________________________________________________________
PERSON TO BE NOTIFIED IN CASE OF ILLNESS OR INJURY________________________________________
ADDRESS______________________________________________________________________________________
PHONE_____________________________________________RELATIONSHIP____________________________
NAME OF INSURANCE COMPANY AND POLICY NUMBER OF YOUR MEDICAL CARE AND HOSPITALIZATION_____________________________________________________________________________
PARTICIPANTS SHOULD BE COVERED BYTHEIR OWN HEALTH AND ACCIDENT INSURANCE
CONSENT TO MEDICAL TREATMENT
I hereby consent to any emergency care, hospital care, medical and surgical diagnosis and/or treatment to be rendered to me as found advisable for any injuries that may arise from my participation in an activity with Pronatura A.C. Veracruz. I understand and agree that I am solely responsible for all applicable charges for such medical treatment, evacuation and rescue. This medical history form is filled out completely and accurately, to the best of my knowledge.
Date_____________________________________Signature_____________________________________________
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MEDICAL HISTORY
PLEASE COMMENT ON SPECIFIC DETAILS OF YOUR MEDICAL HISTORY INCLUDING DATES OF HEALTH CONDITIONS, SPECIFIC MEDICATION NAMES, EFFECTS OF NOT TAKING MEDICATION AND CURRENT STATUS OF CONDITIONS. CIRCLE WHICH CONDITION(S) YOU MAY HAVE!!
1. Problems with hearing or vision which requires a hearing aid, glasses, soft or hard contact lenses? YES_____NO____
2. Problems with teeth; use of denture or bridge? YES_____NO____
3. Palpitations of the heart, irregular heartbeat, heart murmurs? YES_____NO____
4. Low or high blood pressure? YES_____NO____
5. Broken bones, joint dislocations, serious sprains? YES_____NO____
6. Joint pains, swelling or stiffness without injuries? YES_____NO____
7. Impaired circulation, or reaction to cold or hot temperatures YES_____NO____
8. Cramps, or heat exhaustion problems YES_____NO____
9. History of diabetes, thyroid trouble, bleeding problems, Epilepsy, hypoglycemia? YES_____NO____
10. Fear of heights, fear of confined spaces? YES_____NO____
11. Special dietary restrictions? YES_____NO____
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12. Frequent nausea, food intolerance's, heartburn? YES_____NO____
13. Allergic to any of the following?
Check and describe the nature of the reaction
[ ] medication (e.g. penicillin, aspirin, sulfa, etc)
[ ] foods (e.g. shellfish, peanuts)
[ ] insect bites (bee sting)
[ ] other_________________________________________________________________________________
14. Previous problems being at altitude? YES_____NO____
15. Dizziness, fainting, convulsions, persistent headaches? YES_____NO____
16. Motion Sickness? YES_____NO____
17. Chronic cough, bronchitis, bloody sputum? YES_____NO____
18. Shortness of breath, Asthma or chest pains on exertion? YES_____NO____
19. Frequent abdominal cramps, severe menstrual cramps? YES_____NO____
20. Hernia? YES_____NO____
21. Kidney Infection or stones? YES_____NO____
22. Please comment on any of the following prior health conditions that may restrict your activity on a Moki Treks trip:
[ ] Prior severe injuries to head, chest, internal organs?
[ ] Prior surgical procedures?
[ ] Prior severe illness requiring hospitalization?
Current level of physical activity: Please be specific (what kind of sports/activities and # of times per week)
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