Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender

Male

Female

Phone

(###)

###

####

Do you speak and understand English?

Yes

No

Does your insurance company require pre-authorization?

No

Yes

Medical equipment (inhalers, etc.)

Yes

No

Seizure within the past year

Yes

No

Hospitalization or emergency room visit within the past year

Yes

No

Neck, back, shoulder, knee, or ankle problems

Yes

No

History of heart attack, by-pass/angioplasty, angina or other heart related illness

Yes

No

Surgery within the last TWO years

Yes

No

Do you have diabetes?

Yes

No

Do you wear contacts or glasses?

Yes

No

Are you pregnant?

Yes

No

Are you under a physician's care?

Yes

No

Other medical issues/illness/symptoms or requirements

Yes

No

Have you had a blood clot or blood disorder?

Yes

No

Do you have high blood pressure (even if being treated with medication)?

Yes

No

Are you a smoker?

Yes

No

Do you have an abnormally high cholesterol level or a special cholesterol diet?

Yes

No

Do you have a family history of heart attack, coronary artery by-pass, angioplasty or sudden unexpected death before age 55?

Yes

No

Do you have unexpected chest pains, shortness of breath, heart palpitations, sweats, dizziness or fainting spells?

Yes

No

Can you swim?

Yes

No

By signing this document, I agree to the following conditions:

(Please check each box to acknowledge)

1) I agree that I will not hold EcoQuest Travel or any of its staff liable for any injuries or accidents that might occur during the course of this trip.

2) I agree to disclose all pre-existing medical conditions and to update EcoQuest Travel if there is a change in my health prior to travel

3) I understand that having adequate medical/evacuation insurance is my responsibility.

4) I agree to pay for any needed evaluation, treatment and evacuation and I understand that I will not receive a refund if I have to leave a trip for any reason.

Today's Date

MM

DD

YYYY