Participant Medical and Personal Information Form


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 Phsyician:   Physician Phone:  

Please evaluate your:

  • General Health: 
  • Physical Condition:

Swimming Ability:

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

Full Covid-19 Vaccination is mandatory at least 14 days prior to the trip.  
Date of 1st dose: Date of 2nd dose:
Date of 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?

If yes, what condition is being treated?  

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

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

Do you wear contact lenses?

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

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

If yes, to what?  

Arthritis

 
Asthma or Hay Fever
 
Cardiovascular disease, heart trouble, heart attack
 
Coronary insufficiency, stroke, coronary occlusion, artiosclerosis
 
Fainting spells or seizure
 
Hepatitis, jaundice or liver disease
 
High blood pressure
 
Low blood pressure

Kidney trouble
 
HIV

Tendonitis, tenosinovitis or carpal tunnel syndrome

Have you had abnormal bleeding associated with previous extraction, surgery, or trauma?
 

Do you have any blood disorder such as anemia?

 

Are you taking any of the following? Please print
the drug name in the space provided.

Antibiotics or sulfa drugs


Anticoagulants (blood thinners)

Antihistamines

Anti-inflammatories

Cortisone (steroids)

Digitalis or drugs for heart condition

Insulin

Nitroglycerin
Pain killers
Other
 

Are you allergic - have you reacted adversely to:

Anti-inflammatories

Aspirin
 
Barbituates, sedatives, sleeping pills
 
Codeine or other narcotics
 
Iodine
 
Local anesthetics
  Penicillin or other antibiotics
Sulfa drugs
Other

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.

Leave this empty:

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Signature Certificate
Document name: Participant Medical and Personal Information Form
lock iconUnique Document ID: 13b7d883ae129f526e9730a1552092f055cbc146
Timestamp Audit
August 31, 2021 6:54 pm PSTParticipant Medical and Personal Information Form Uploaded by Ocean Light Adventures - adventure@oceanlight.ca IP 50.98.193.206
December 1, 2021 11:28 am PST Document owner luke@shiftcreative.ca has handed over this document to adventure@oceanlight.ca 2021-12-01 11:28:02 - 207.6.85.155