OCEAN LIGHT ADVENTURES LTD. MEDICAL AND PERSONAL INFORMATION FORM

Please complete this form to the best of your ability as it is in the best interest of yourself, your fellow trip members, and your guides that all of the information provided is accurate and complete. Completion of this form is mandatory for trip participation and must be returned at least 30 days prior to departure. Your answers are for our records and will be considered absolutely confidential.

Participant's Name:   Today's Date:

Trip Name:   Trip Start Date:

Date of Birth: Gender:   Height:   Weight:  

Emergency Contact Name:    Phone:  
Name of Physician:   Physician Phone:  

Please evaluate your:

• General Health:  FairGoodExcellent
• Physical Condition: Below AverageAverageAbove AverageExcellent

Swimming Ability: Non-swimmerPoorFairGoodExcellent

Tetanus Shot within last 10 years is mandatory.  Date of inoculation:  

Have you had any Covid-19 vaccinations?:  
Date of last booster (Optional):

Has there been a change in your general health this past year?

 If yes, please explain:  

Are you now under the care of a physician? YesNo

If yes, what condition is being treated?  

Have you been hospitalized or had serious injury within the past 5 years? YesNo

If yes, what was the nature of the issue and the date?  

Do you wear contact lenses? YesNo

 
Do you have any serious trouble associated with a previous dental treatment? YesNo 

Please list any special dietary requirements or food allergies for medical reasons: NOTE: We will do our best to accommodate your food preferences but it is not always possible.

Please list your food allergies:

Please list your food preferences:

Do you have, or have you had, any of the following diseases or problems? Allergies YesNo If yes, to what?   Arthritis YesNo Asthma or Hay Fever YesNo   Cardiovascular disease, heart trouble, heart attack YesNo   Coronary insufficiency, stroke, coronary occlusion, artiosclerosis YesNo   Fainting spells or seizure YesNo   Hepatitis, jaundice or liver disease YesNo   High blood pressure YesNo   Low blood pressure YesNo Kidney trouble YesNo   HIV YesNo Tendonitis, tenosinovitis or carpal tunnel syndrome YesNo Have you had abnormal bleeding associated with previous extraction, surgery, or trauma? YesNo   Do you have any blood disorder such as anemia? YesNo

Are you taking any of the following? Please print the drug name in the space provided. Antibiotics or sulfa drugs YesNo Anticoagulants (blood thinners) YesNo Antihistamines YesNo Anti-inflammatories YesNo Cortisone (steroids) YesNo Digitalis or drugs for heart condition YesNo Insulin YesNo Nitroglycerin YesNo Pain killers YesNo Other YesNo   Are you allergic? - have you reacted adversely to: Anti-inflammatories YesNo Aspirin YesNo   Barbituates, sedatives, sleeping pills YesNo   Codeine or other narcotics YesNo   Iodine YesNo   Local anesthetics YesNo   Penicillin or other antibiotics YesNo Sulfa drugs YesNo Other YesNo

Do you have any condition or problem not listed above that you think we should know about? Please explain:

I am medically, physically and in all other respects, fit and fully able to participate in adventure travel and have no special medical requirements or conditions except as noted above. Should there be any change(s) related to my health or my ability to participate in the trip, I will notify the guides immediately.  Before signing, please double check this document for accuracy, as it cannot be edited later.