| Expedition Medical Services|
CONFIDENTIAL MEDICAL QUESTIONNAIRE
Each member of the Expedition is asked to complete this questionnaire, which will be held personally and in confidence by Dr Dick Morgan, to facilitate appropriate medical support and pre-expedition medical screening. I am prepared to have individuals with medical problems on the expedition so long as full disclosure has been made in advance and agreed following discussions. It is unfair on other expedition members if the trip is compromised by undeclared pre-existing illnesses. Each individual must ensure that they are adequately medically insured. Individuals are also responsible for bringing adequate quantities of any regular medication they are taking. I suggest bringing double the anticipated quantity for 3 weeks and keeping it in 2 separate locations in case one lot goes missing. If you ask your GP nicely (a nominal fee may be payable) you can get a computer summary printed out which will list medication & major illnesses you have suffered in the past. This is very useful for you to hold when travelling abroad – and a photocopy for my records would be very helpful.
NAME: Surname: First Name: Date of Birth:
NATIONALITY: Passport Number:
TELEPHONE: Home: Office email:
NEXT OF KIN: Name: Address:
GP: Dr’s Name: Surgery Address:
Dr’s Telephone: Fax: email:
SERIOUS MEDICAL ILLNESSES / Previous Operations:
Please give rough dates and indicate whether the problem is ongoing or not. If you have to see your GP or Hospital specialist for regular check-ups please indicate why.
MEDICATION: ANY ALLERGIES TO DRUGS?
Please list any current medication you are taking – both regularly and on an as needed basis
In the event of anything mentioned in this questionnaire giving me concern about your fitness to travel I will contact you to discuss the situation. If necessary, with your permission, I will speak to your GP. If at the end of the day I consider that your medical condition makes you an unreasonable risk on the expedition either to yourself or to the other members I reserve the right to decline your application. Please raise concerns early on!