Medical Information Form

Do you have any of the following? *
	No	Yes
Raised blood pressure
Joint or Mobility problems in last 12 months
Heart or circulatory disease
Chest /lung disease
Diabetes
Epilepsy/neurological problem
Digestive or bowel disorders
Asthma
Surgical operations in the last 12 months
Mental/emotional instability
Pregnancy

Any other health / medical issues?
No Yes - specify:
Blood Pressure
Pulse
Fitness *

(An idea of reasonable fitness is the ability to walk over rough ground with a daypack for 7 hours with only short stops)
Age *
Height (cm) *
Weight (kg) *
ESSENTIAL INFORMATION

Provide details / List of medication / Allergy to drugs, chemicals or food:
Medications, allergies:
DECLARATION

Please read and tick if you acknowledge the below.
I acknowledge that I have been requested by Tenzing's Journeys to complete a medical form to qualify my physical and emotional fitness for my forthcoming holiday. I confirm that the information provided is true and accurate, and agree to it being shared with the trip leader. I confirm that Tenzing's Journeys will bear no liability should a medical matter arise that I have not disclosed on my medical form and that I shall be financially responsible for any consequent medical expenses. I acknowledge that my doctor must complete this form if I have a pre-existing medical condition (indicated YES to any of the questions above) or if I am over 70 years of age.
I acknowledge that if I have any pre-existing medical conditions, such as asthma, high blood pressure/heart disease, diabetes, epilepsy or mental illness, that I will discuss it with my doctor before my trip.
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4, 5, 6, 7 : the 2nd number is?