Today's Date
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MM
DD
YYYY
Name
*
First Name
Last Name
Height in cm
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Weight in KG
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Date of Birth
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MM
DD
YYYY
Age
*
Gender identity
*
Have you had any significant medical, surgical or mental health conditions in the past?
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If YES, please provide details:
Do you have any physical or mental health conditions requiring treatment or medical supervision at this time?
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If YES, please provide details:
Have you undergone any surgical procedure in the last year?
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If YES, please provide details:
Are you taking any drugs or other medication, including anti-coagulants, or receiving chemotherapy?
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If YES, please provide details of, the drug, the dosage you take and the reason for taking it for each medication.
Do you have any allergies?
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If YES, please give details of what are you allergic to, whether your reaction is mild/moderate/severe. And whether you carry any drugs such as an epipen for your allergy.
Angina (cardiac)
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Myocardial infarction (heat attack)
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High blood pressure
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Other heart disease
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Cardiovascular accident (stroke)
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Transient ischaemic attack
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Peripheral vascular disease
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Asthma
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Epilepsy
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Thyroid disease
*
Bleeding disorders
*
Depression
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Other mental health conditions
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Cancer
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Altitude illness
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Back problems
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If you answered YES to any of the previous check boxes, please provide full details of anything not previously disclosed, including severity, symptoms, medications and treatment
Do you have any physical limitations or disabilities Do you use any artificial aids, e.g. wheelchair, stick, prosthetic?
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If YES, please provide details:
Have you ever had frostbite or other cold injury?
*
If YES, please provide details:
Physician Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
Country
(###)
###
####
Email
Please check the box below. Checking the box confirms:
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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.
