Personal Information Form - Wild Trek Tours

Details in this form must be the same as appears in your passport. Please complete one form for each individual

    Emergency contact details :

    Emergency contact #1

    Emergency contact #2

    Trek details

    T-Shirt size

    SMLXLXXL

    Health questionnaire

    Have you ever had an asthma attack that required medical assistance over the last 12 months?

    YesNo

    Have you ever had a heart attack or stroke ?

    YesNo

    Do you have diabetes and have you had issues controlling your blood sugar within the last 3 months?

    YesNo

    Have you ever experienced unexplained pains in your chest at rest or during physical activity?

    YesNo

    Have you any joint or other similar conditions where you may have been told it could worsen with physical activity?

    YesNo

    Is there any family history of heart disease?

    YesNo

    Are you a smoker?

    YesNo

    Please describe your current physical activity and exercise level :

    Very littleLightModerateVigorous

    Do you have high cholesterol?

    YesNo

    Do you have high blood pressure?

    YesNo

    Do you have high blood sugar?

    YesNo

    Are you pregnant or have you given birth in the last 12 months ?

    YesNo

    Have you spent time in hospital (including day admission) for any medical condition within the last 12 months?

    YesNo

    Are you currently taking any prescribed medication?

    YesNo

    NOTE : IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, FURTHER INFORMATION MUST BE OBTAINED FROM YOUR MEDICAL PRACTIONER, AND DETAILED ON THE WILD TREK MEDICAL FORM, AND YOUR DOCTOR MUST STATE YOU ARE MEDICALLY FIT TO UNDERTAKE THE TREK.

    We recommend you print a copy for your personal records prior to checking the acceptance button.