Please complete this questionnaire carefully. It is very important that we find out as much as possible about your medical history to ensure your safety on the challenge. We will treat your questionnaire with the strictest confidence. We will attempt to accommodate everybody on the challenge, but do reserve the right to refuse entry on medical grounds if we feel your safety and/or that of the group may be compromised. Any decision will be made in consultation with you.
Do you suffer from or have you ever suffered from:
Heart trouble and/or blood pressure problems?
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Asthma, bronchitis and/or shortness of breath?
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Diabetes?
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Epilepsy and/or fainting attacks?
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Migraine, headaches?
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Severe head injuries?
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Cancer?
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Allergies?
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Vertigo?
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Fracture, tendon or ligament/cartilage damage?
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Physical illness or back problems?
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Psychiatric or mental illness?
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Have you been hospitalised within the last two years?
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Are you suffering from or a carrier of any infectious disease?
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Are you registered as disabled?
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Do you have any skin wounds or ulcers?
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Do you have any problems with sight, hearing or other senses?
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Do you have any other on-going or past medical problems?
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Are you pregnant or trying to get pregnant?
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Do you have a drug or alcohol dependency?
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If you answered yes to any of the above questions, please give details here :
If you answered YES to the question regarding asthma, please answer the following:
When was the last time you needed hospital treatment?
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When was the last time you needed steroid tablets?
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What medication/inhalers do you currently use?
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Are you currently taking any medication? If so please give details
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If you have any medical conditions which may be affected by strenuous activity, or you are over 60, you must get written clearance from your doctor. Please download this consent form , get it signed by your doctor, and submit it to us with your registration cheque.
In case of an emergency, please contact:
Medical Declaration
Please make a selection. By ticking this box, I confirm that:
I understand and agree that my personal data may be processed and/or transferred outside of the European economic area in order for the full and proper performance of the challenge contract. I understand that Action Challenge UK Ltd. will only transfer to the extent required.
I hereby give permission for Action Challenge UK Ltd. or other expedition staff to initiate medical treatment and to inform my emergency contact if I go to hospital while on the event.
To the best of my knowledge, this is a true and accurate description of my medical history and my current condition.
