ACROSS THE DIVIDE OPEN CHALLENGES
MEDICAL QUESTIONNAIRE

Please complete this questionnaire as part of your registration. It is for your own safety that we find out as much as possible about your medical history. This will ensure that you can cope with the rigours of the trek. All your answers will be treated in the strictest confidence and will not necessarily adversely affect your chance to take part. We will attempt to accommodate everybody, but do reserve the right to refuse participation on medical grounds if we feel your safety, and that of the group, may be compromised. Any decision made will be in consultation with you and your GP. Should any of your medical details change after you have completed this form then you must inform us.

Failure to divulge the full details of any medical condition from which you suffer will invalidate your insurance and mean you will have to pay for any medical expenditure and repatriation, which can result in thousands of pounds.

 

* = these fields are mandatory

The event I am entering is:

1. Personal Details

*Title:

*First Name:

*Surname:

*Email:

*Date of Birth:

Age:

Daytime phone number:

Mobile phone number:

Evening phone number:

*Name of your GP:

*GP phone number:

2. Do you suffer or have you ever suffered from:

Vertigo?



Heart trouble and/or blood pressure problems?
Asthma, bronchitis and/or shortness of breath?



Diabetes?



Epilepsy and/or fainting attacks?



Migraine?



Severe head injury?



Back problems?



Allergies? Please note that horses are used as support on some of the treks



Fractures, tendon, ligament/cartilage damage?



Physical or other disability?



Psychiatric or mental illness?



Have you attended hospital for any investigations/treatment in the last two years?



Are you suffering from or a carrier of any infectious diseases?



Are you registered as disabled?



Are you pregnant?



Do you smoke?



Do you suffer from any other conditions that are not stated above?



3. If you have answered yes to any of the above questions, please give further details below

4. Have you ever suffered from asthma?


If you answered yes to question 4,

When was the last time you needed hospital treatment?
When was the last time you needed steroid tablets?
What medication/inhalers do you use?

5. Do you currently use any form of medication regularly?

  

If yes, please give details

Next of Kin (Please give full name, address and telephone numbers)

*Name:

*Address:

Daytime Phone Number:

Evening Phone Number:

*Mobile Phone Number:

Relationship:

In the event of an accident of illness while on the trip, I hereby give permission for Across the Divide Ltd medical or expedition staff to initiate medical treatment and to inform my next of kin in case of hospitalisation.

To the best of my knowledge this is a true and accurate description of my medical history and current condition. I understand that I am also responsible for informing Across the Divide of any change in my medical condition, including pregnancy, which may arise between now and the departure date. I understand that failure to do so will invalidate my insurance.

Participants must agree to inform Across the Divide of any medical or other condition that might affect their ability to take part in the event.

If you are over 60 OR have answered ‘YES’ to any of the questions on the medical form (except smoking) you will need to be signed off by your GP. Please download, complete and return this medical form.

 

 

 

 

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