Medical Form Name * First Name Last Name Date of Birth * MM DD YYYY Emergency Contact * First Name Last Name Emergency Contact Relationship * Emergency Contact Phone Number * Country (###) ### #### Do you have any dietary requirements? Have you ever been diagnosed with or experienced any of the following? (Please check all that apply and provide details where necessary) * Asthma Diabetes Heart Disease or Heat Conditions High or Low Blood Pressure Seizures or Epilepsy Respiratory Conditions (e.g., chronic bronchitis, emphysema, etc.) Musculoskeletal injuries or conditions (e.g., joint issues, recent fractures, etc.) Mental health conditions (e.g., anxiety, depression, panic attacks, etc.) Allergies (e.g., food, medications, insect bites, etc.) History of altitude sickness Other medical conditions or surgeries None of the above If you checked any of the above, please provide further details Are you currently taking any prescription or over-the-counter medications, including herbal supplements or vitamins? * Yes No If yes, please list the medication(s) and the condition they are being used for Do you have any allergies (including medications, food, insects, or environmental allergens)? * Yes No If yes, please provide details, including the severity of the reaction and any required treatment How would you rate your current physical fitness level? * Excellent Good Average Poor Do you regularly engage in physical activities such as hiking, running, cycling, or gym workouts? * Yes No Have you previously participated in multi-day hikes or trekking at high altitudes (above 2,500 meters)? * Yes No Have you ever experienced altitude sickness or other symptoms while hiking or traveling at high elevations (e.g., headaches, nausea, dizziness, shortness of breath)? * Yes No Do you require any medical equipment during the trek (e.g., inhalers, insulin pumps, CPAP machines)? * Yes No Is there any other medical or personal information you believe we should be aware of to ensure your safety during the trek? Do you have travel insurance that covers hiking, adventure activities, and medical repatriation for the location of the tour? * Yes No, but I confirm that I will purchase suitable travel insurance before the tour start date By submitting this form you confirm that the above information is accurate and complete to the best of your knowledge. You understand that it is your responsibility to inform the guide or trek leader if there are any changes to your health or medical condition before or during the trek. You also acknowledge that failure to disclose relevant medical information could result in exclusion from the trek or medical complications during the trek * Yes Thank you!
