These sample questionnaires are issued for you to complete in private. You are not being asked to hand them in, or reveal the details to anyone else, but they may have some bearing on whether you go or not. It is your choice to go or not. Perhaps put appropriate details in an envelope in the glove box. But please contact the trip leader/s if you are unsure, or if it is appropriate that they know of any condition or concern.(Some questions have been modified from the original).
From: http://www.sorenlarsen.co.nz/Medical3.htm
Medical Questions
Have you ever had epilepsy?
Do you ever faint or have blackout spells?
Do you have diabetes? If yes, for how long? If yes, what medication are you on for diabetes?
Are you pregnant? If yes, at what stage?
Have you ever had a major operation? Please detail
Is a doctor presently treating you?
Are you taking any regular medication? Please detail
Do you have any blood or bleeding disorders?
Have you any lung or bronchial disorders?
Do you have high blood pressure?
Have you had angina or a heart attack?
Do you get fatigued or short of breath easily?
Do you suffer from any joint or dislocation problems?
Do you have any back problems?
Do you have any limiting physical handicap? (Including sight/hearing problems)
Is there anything else that we should know about that could affect your ability to undertake the voyage?
Treatment for mental illness or depression (past or present) must be included
Do you undertake any regular strenuous exercise?
Are you allergic to any foods or medications (e.g. Penicillin) or have any known reactions to drugs & medication?
From: http://www.skillcentre.tas.edu.au/Shortcourses/medical_questionnaire.htm
Tasmanian Board of Canoe Education
Medical questionnaire & consent form
1. Do you suffer from any medical condition, illness, injury or disability that may interfere with or be aggravated by the proposed activity?
YES / NO
If YES, please give details below
2. Is the abovementioned condition likely to require any special attention, treatment or medication during the activity?
YES / NO
If YES, please give details below (including nature and availability)
3. Have you ever had a serious allergic reaction to an insect, animal or plant? YES / NO
If YES, please give details below (including reaction and treatment)
4. Can you swim the length of an Olympic swimming pool? YES / NO
If NO, please give details below
From: Landscope Expeditions Program brochure 2003/2004
Application & medical conditions:
Do you have Diabetes, Epilepsy, Asthma, heart condition, allergies (please list below), other.
Do you have any other physical/medical conditions of which your project leader should be aware?
(e.g. medication, sleepwalking, bad back, previous hospitalisation, major injuries or loss of consciousness).
Submitted by Ian Johnson @10/2014