Medical Form

We ask for the following information so that our staff will know in advance of special medical conditions you may have in the event of injury or illness.

We may also require this information for the purchase of travel insurance and a failure to declare any conditions could result in a claim not being covered.

The information on this form will be kept confidential and is only for use by our staff.

Today's Date *
Today's Date
Name *
Name
Date of Birth *
Date of Birth
Gender identity *
PAST MEDICAL CONDITIONS
Have you had any significant medical, surgical or mental health conditions in the past? *
PRESENT MEDICAL CONDITIONS
Do you have any physical or mental health conditions requiring treatment or medical supervision at this time? *
Have you undergone any surgical procedure in the last year? *
Are you taking any drugs or other medication, including anti-coagulants, or receiving chemotherapy? *
Do you have any allergies? *
PRE-EXISTING CONDITIONS
Do you have, or have you ever had any of the following specific conditions?
Angina (cardiac) *
Myocardial infarction (heat attack) *
High blood pressure *
Other heart disease *
Cardiovascular accident (stroke) *
Transient ischaemic attack *
Peripheral vascular disease *
Asthma *
Epilepsy *
Thyroid disease *
Bleeding disorders *
Depression *
Other mental health conditions *
Cancer *
Altitude illness *
Back problems *
Do you have any physical limitations or disabilities Do you use any artificial aids, e.g. wheelchair, stick, prosthetic? *
Have you ever had frostbite or other cold injury? *
YOUR PERSONAL PHYSICIAN
If you have any medical issues that may affect your fitness to participate you are advised to seek advice from your own physician. Please give the details of your primary medical care provider:
Physician Name
Physician Name
Address
Address
Phone
Phone
DECLARATION
Please check the box below. Checking the box confirms: *
1.That you have read your course guidelines and are fit to undertake your chosen activity; 2. That you have provided accurate and complete information on your medical condition; 3. Your consent for Polar Expedition Training LLC to seek further medical information from your personal Physician after first notifying you of that intention; 4. That you will inform Polar Expedition Training LLC of any change in your medical details prior to the start of your course; 5. The right of Polar Expedition Training LLC to adapt or curtail your program due to medical or physical circumstances.
This entry constitutes your electronic signature