| MCA FORM 3: Participant Medical Information Climbing and trekking at high altitudes is extremely strenuous. In addition, medical care as you may be accustomed to at home in Canada or the US is non-existent in many foreign countries. We do not want you to engage in any activity that would be detrimental to your health or which would be opposed by your doctor because of recent illness, injury, surgery, etc. If you have any questions regarding your participation in the expedition, please contact your doctor.
Gender: ____________________ Height: ____________________ Weight: _____________________ How would you describe your health (use additional page if necessary?) __________________________ ____________________________________________________________________________________ Please answer the following questions. If yes to any, please describe on a separate sheet. Have you
ever had (YES or NO): Frostbite ________ Do you get cold easily? ________ Shoulder, Back, or Knee problems ________ Diabetes ________ Are you pregnant? ________ Asthma ________ Epilepsy ________ Heart Disease ________ Cerebral or Pulmonary Edema ________ Previous altitude problems ________ Speech, vision, or hearing impairment ________ Do you use tobacco? If yes, details ______________________________________________________ Are you taking any medications (for what? dosage? use additional page if necessary)? ____________________________________________________________________________________ ____________________________________________________________________________________ Do you have any limitations on your activities (use additional page if necessary)? ____________________________________________________________________________________ ____________________________________________________________________________________ Do you have any other conditions that might affect your health (use additional page if necessary)? ____________________________________________________________________________________ AGREEMENT
Participant’s Signature: ____________________________________Date_______________________ If under
18, Parent or Guardian must also sign: Parent please
print full name: _________________________________________________________ |