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Medical Form

GENERAL MEDICAL INFORMATION

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If the answer to any of the following questions is YES, please provide further details.
(e.g., dates of illness, treatment undergone, etc.)

Full Name(*)
Please type your full name.

Date(*)
Please select a date when we should contact you.

Date of Birth
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E-mail(*)
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Height
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TripName
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Blood Type
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MEDICAL HISTORY

During the last 5 years, have you suffered any significant illness, been hospitalized or required regular care by a doctor?(*)
Please specify your position in the company

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Have you ever had any of the following:

Asthma, tuberculosis, chronic bronchitis, emphysema or any other lung problems?
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High blood pressure, heart problems, or rheumatic fever?
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Gout or arthritis or any back, leg or foot problems?
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Gastric or duodenal ulcer, colitis or intestinal trouble?
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Epilepsy or fits of any kind?
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Depression, anxiaty or mental disorder?
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Kidney or bladder disease?
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Diabetes, cancer or tumor of any kind?
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Do you have any allergies or reactions to drugs?
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Do your have any physical or mental limitations, handicaps or prosthesis? Do your have difficulty walking or using crutches, cane or wheelchair?
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Are you pregnant? If so, how many weeks pregnant will you be at time of travel?
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MEDICAL ADVISOR’S INFORMATION

Please give this form along with your trip itinerary to your personal physician. The traveler is planning an adventure trip to a remote area, where sophisticated medical facilities are unavailable. We would like to be sure that each of our passengers is in adequate medical condition for the trip, and that we are fully alerted to any potential health problems. Please note that our trips have different degrees of difficultties. While not strenuous, travellers who participate on such excursions must negotiate a steep gangway, get in and out of landing boats with assistance, and be capable of walking a short distance over uneven and slippery terrain ashore. Please feel free to call us if you have any questions.

CURRENT MEDICATIONS

Please list below:

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I, have read and understand the tour itinerary and am aware of the physical requirements of the trip. I declare that is physically and psychologically fit to participate in .
I declare the answers to the above questions are true and complete. I agree to this information being made available to One Earth Peru.

I Agree
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Date
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Comments
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(*)
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Office (51 1) 231 5390 | Cell Phones (51) 965744055 – 965743906 | one@oneearthperu.com | We Accept Visa