Participant 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:  

Have you had any Covid-19 vaccinations?:
Date of 1st dose: Date of 2nd dose:
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?

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?


If yes, to what?  


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

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)



Cortisone (steroids)

Digitalis or drugs for heart condition


Pain killers

Are you allergic - have you reacted adversely to:


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

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.

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Signature Certificate
Document name: Participant Medical and Personal Information Form
lock iconUnique Document ID: d917df372f056a4c5c17e52e5a93d32c8445eb45
Timestamp Audit
August 31, 2021 6:54 pm PDTParticipant Medical and Personal Information Form Uploaded by Ocean Light Adventures - IP
December 1, 2021 11:28 am PDT Document owner has handed over this document to 2021-12-01 11:28:02 -