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COLORADO ADVENTURE GUIDES

HEALTH HISTORY QUESTIONNAIRE

This information is for the guide only and is completely confidential.

Colorado Adventure Guides trips may be half-day, full-day, or multi-day wilderness expeditions in remote settings, where evacuation to modern hospital facilities is not immediately possible. You must expect extreme weather conditions ranging from snow storms to sleet to extreme heat. Sudden environmental changes are to be expected and anticipated. Depending on what activity you pursue with COLORADO ADVENTURE GUIDES you may be required to walk for several hours; carry a heavy load up uneven, steep terrain; sleep outdoors; experience long, tough days; and prepare meals and set up camp. If you have any questions about the activity and your participation, you may contact COLORADO ADVENTURE GUIDES directly.

Participant: Please circle YES or NO for each question. Each must be answered, but keep in mind that a “YES” answer does not necessarily mean you will not be able to participate. If you answer “YES” to any question, you may be asked to discuss your condition with the guide before departing. Guides reserve the right to make a decision on a participant’s eligibility at any time.

PLEASE READ CAREFULLY BEFORE SIGNING

The information provided above is a complete and accurate statement of any physical and psychological conditions, which may affect my participation in this trip. I realize that failure to disclose such information could result in serious harm to me, fellow participants, the guide. I agree to inform COLORADO ADVENTURE GUIDES should there be any change in my health status prior to the start of the trip. On the basis of the background information at the beginning of this form, and what I know or suspect about my physical and psychological health, I am fully capable of participating in this activity. I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to carry the proper medication with me.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Health History

Do you currently have or have a general medical history of:

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you marked "YES" on any of the above General Medical History questions, please provide a brief description of your condition and any associated physical limitations:

Do you currently have or have a history of any of the following Musculoskeletal Injuries:

19a. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones (including sprains)? If so, please explain in 19b.*
No
Yes

19b. If so, please explain:
20a. Have any of these injuries required surgery? If so, please explain in 20b.*
No
Yes

20b. Please explain surgeries

Allergies/Medications

21a. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

21b. If you have alergies, please list them, along with their severity and current treatment plan:
22. Are you allergic to any medications?*
No
Yes
23a. Are you currently taking any medications?*
No
Yes

23b. What is the medication dosage and schedule?
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes
27a. Do you have any other physical, medical, or psychological conditions not listed above? Please list them in 27b.*
No
Yes

27b. Please list the conditions here.

Fitness

28a. Do you exercise regularly?*
No
Yes

28b. How often?

28c. If you have any fitness restrictions, please list them here.

28d. Duration/Distance:
28e. Intensity Level:*
Easy
Moderate
Competitive
29a. Do you smoke?*
No
Yes

29b. If you smoke, how much?
30. Swimming ability:*
Swimmer
Non-swimmer

Diet


31. Please list any dietary restrictions or food allergies. Are you vegetarian, vegan, gluten-free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when exposed to the allergen?
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Health History

Do you currently have or have a general medical history of:

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you marked "YES" on any of the above General Medical History questions, please provide a brief description of your condition and any associated physical limitations:

Do you currently have or have a history of any of the following Musculoskeletal Injuries:

19a. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones (including sprains)? If so, please explain in 19b.*
No
Yes

19b. If so, please explain:
20a. Have any of these injuries required surgery? If so, please explain in 20b.*
No
Yes

20b. Please explain surgeries

Allergies/Medications

21a. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

21b. If you have alergies, please list them, along with their severity and current treatment plan:
22. Are you allergic to any medications?*
No
Yes
23a. Are you currently taking any medications?*
No
Yes

23b. What is the medication dosage and schedule?
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes
27a. Do you have any other physical, medical, or psychological conditions not listed above? Please list them in 27b.*
No
Yes

27b. Please list the conditions here.

Fitness

28a. Do you exercise regularly?*
No
Yes

28b. How often?

28c. If you have any fitness restrictions, please list them here.

28d. Duration/Distance:
28e. Intensity Level:*
Easy
Moderate
Competitive
29a. Do you smoke?*
No
Yes

29b. If you smoke, how much?
30. Swimming ability:*
Swimmer
Non-swimmer

Diet


31. Please list any dietary restrictions or food allergies. Are you vegetarian, vegan, gluten-free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when exposed to the allergen?
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Health History

Do you currently have or have a general medical history of:

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you marked "YES" on any of the above General Medical History questions, please provide a brief description of your condition and any associated physical limitations:

Do you currently have or have a history of any of the following Musculoskeletal Injuries:

19a. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones (including sprains)? If so, please explain in 19b.*
No
Yes

19b. If so, please explain:
20a. Have any of these injuries required surgery? If so, please explain in 20b.*
No
Yes

20b. Please explain surgeries

Allergies/Medications

21a. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

21b. If you have alergies, please list them, along with their severity and current treatment plan:
22. Are you allergic to any medications?*
No
Yes
23a. Are you currently taking any medications?*
No
Yes

23b. What is the medication dosage and schedule?
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes
27a. Do you have any other physical, medical, or psychological conditions not listed above? Please list them in 27b.*
No
Yes

27b. Please list the conditions here.

Fitness

28a. Do you exercise regularly?*
No
Yes

28b. How often?

28c. If you have any fitness restrictions, please list them here.

28d. Duration/Distance:
28e. Intensity Level:*
Easy
Moderate
Competitive
29a. Do you smoke?*
No
Yes

29b. If you smoke, how much?
30. Swimming ability:*
Swimmer
Non-swimmer

Diet


31. Please list any dietary restrictions or food allergies. Are you vegetarian, vegan, gluten-free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when exposed to the allergen?
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Health History

Do you currently have or have a general medical history of:

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you marked "YES" on any of the above General Medical History questions, please provide a brief description of your condition and any associated physical limitations:

Do you currently have or have a history of any of the following Musculoskeletal Injuries:

19a. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones (including sprains)? If so, please explain in 19b.*
No
Yes

19b. If so, please explain:
20a. Have any of these injuries required surgery? If so, please explain in 20b.*
No
Yes

20b. Please explain surgeries

Allergies/Medications

21a. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

21b. If you have alergies, please list them, along with their severity and current treatment plan:
22. Are you allergic to any medications?*
No
Yes
23a. Are you currently taking any medications?*
No
Yes

23b. What is the medication dosage and schedule?
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes
27a. Do you have any other physical, medical, or psychological conditions not listed above? Please list them in 27b.*
No
Yes

27b. Please list the conditions here.

Fitness

28a. Do you exercise regularly?*
No
Yes

28b. How often?

28c. If you have any fitness restrictions, please list them here.

28d. Duration/Distance:
28e. Intensity Level:*
Easy
Moderate
Competitive
29a. Do you smoke?*
No
Yes

29b. If you smoke, how much?
30. Swimming ability:*
Swimmer
Non-swimmer

Diet


31. Please list any dietary restrictions or food allergies. Are you vegetarian, vegan, gluten-free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when exposed to the allergen?
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Health History

Do you currently have or have a general medical history of:

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you marked "YES" on any of the above General Medical History questions, please provide a brief description of your condition and any associated physical limitations:

Do you currently have or have a history of any of the following Musculoskeletal Injuries:

19a. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones (including sprains)? If so, please explain in 19b.*
No
Yes

19b. If so, please explain:
20a. Have any of these injuries required surgery? If so, please explain in 20b.*
No
Yes

20b. Please explain surgeries

Allergies/Medications

21a. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

21b. If you have alergies, please list them, along with their severity and current treatment plan:
22. Are you allergic to any medications?*
No
Yes
23a. Are you currently taking any medications?*
No
Yes

23b. What is the medication dosage and schedule?
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes
27a. Do you have any other physical, medical, or psychological conditions not listed above? Please list them in 27b.*
No
Yes

27b. Please list the conditions here.

Fitness

28a. Do you exercise regularly?*
No
Yes

28b. How often?

28c. If you have any fitness restrictions, please list them here.

28d. Duration/Distance:
28e. Intensity Level:*
Easy
Moderate
Competitive
29a. Do you smoke?*
No
Yes

29b. If you smoke, how much?
30. Swimming ability:*
Swimmer
Non-swimmer

Diet


31. Please list any dietary restrictions or food allergies. Are you vegetarian, vegan, gluten-free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when exposed to the allergen?
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Health History

Do you currently have or have a general medical history of:

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you marked "YES" on any of the above General Medical History questions, please provide a brief description of your condition and any associated physical limitations:

Do you currently have or have a history of any of the following Musculoskeletal Injuries:

19a. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones (including sprains)? If so, please explain in 19b.*
No
Yes

19b. If so, please explain:
20a. Have any of these injuries required surgery? If so, please explain in 20b.*
No
Yes

20b. Please explain surgeries

Allergies/Medications

21a. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

21b. If you have alergies, please list them, along with their severity and current treatment plan:
22. Are you allergic to any medications?*
No
Yes
23a. Are you currently taking any medications?*
No
Yes

23b. What is the medication dosage and schedule?
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes
27a. Do you have any other physical, medical, or psychological conditions not listed above? Please list them in 27b.*
No
Yes

27b. Please list the conditions here.

Fitness

28a. Do you exercise regularly?*
No
Yes

28b. How often?

28c. If you have any fitness restrictions, please list them here.

28d. Duration/Distance:
28e. Intensity Level:*
Easy
Moderate
Competitive
29a. Do you smoke?*
No
Yes

29b. If you smoke, how much?
30. Swimming ability:*
Swimmer
Non-swimmer

Diet


31. Please list any dietary restrictions or food allergies. Are you vegetarian, vegan, gluten-free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when exposed to the allergen?
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Health History

Do you currently have or have a general medical history of:

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you marked "YES" on any of the above General Medical History questions, please provide a brief description of your condition and any associated physical limitations:

Do you currently have or have a history of any of the following Musculoskeletal Injuries:

19a. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones (including sprains)? If so, please explain in 19b.*
No
Yes

19b. If so, please explain:
20a. Have any of these injuries required surgery? If so, please explain in 20b.*
No
Yes

20b. Please explain surgeries

Allergies/Medications

21a. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

21b. If you have alergies, please list them, along with their severity and current treatment plan:
22. Are you allergic to any medications?*
No
Yes
23a. Are you currently taking any medications?*
No
Yes

23b. What is the medication dosage and schedule?
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes
27a. Do you have any other physical, medical, or psychological conditions not listed above? Please list them in 27b.*
No
Yes

27b. Please list the conditions here.

Fitness

28a. Do you exercise regularly?*
No
Yes

28b. How often?

28c. If you have any fitness restrictions, please list them here.

28d. Duration/Distance:
28e. Intensity Level:*
Easy
Moderate
Competitive
29a. Do you smoke?*
No
Yes

29b. If you smoke, how much?
30. Swimming ability:*
Swimmer
Non-swimmer

Diet


31. Please list any dietary restrictions or food allergies. Are you vegetarian, vegan, gluten-free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when exposed to the allergen?
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Health History

Do you currently have or have a general medical history of:

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you marked "YES" on any of the above General Medical History questions, please provide a brief description of your condition and any associated physical limitations:

Do you currently have or have a history of any of the following Musculoskeletal Injuries:

19a. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones (including sprains)? If so, please explain in 19b.*
No
Yes

19b. If so, please explain:
20a. Have any of these injuries required surgery? If so, please explain in 20b.*
No
Yes

20b. Please explain surgeries

Allergies/Medications

21a. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

21b. If you have alergies, please list them, along with their severity and current treatment plan:
22. Are you allergic to any medications?*
No
Yes
23a. Are you currently taking any medications?*
No
Yes

23b. What is the medication dosage and schedule?
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes
27a. Do you have any other physical, medical, or psychological conditions not listed above? Please list them in 27b.*
No
Yes

27b. Please list the conditions here.

Fitness

28a. Do you exercise regularly?*
No
Yes

28b. How often?

28c. If you have any fitness restrictions, please list them here.

28d. Duration/Distance:
28e. Intensity Level:*
Easy
Moderate
Competitive
29a. Do you smoke?*
No
Yes

29b. If you smoke, how much?
30. Swimming ability:*
Swimmer
Non-swimmer

Diet


31. Please list any dietary restrictions or food allergies. Are you vegetarian, vegan, gluten-free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when exposed to the allergen?
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Health History

Do you currently have or have a general medical history of:

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you marked "YES" on any of the above General Medical History questions, please provide a brief description of your condition and any associated physical limitations:

Do you currently have or have a history of any of the following Musculoskeletal Injuries:

19a. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones (including sprains)? If so, please explain in 19b.*
No
Yes

19b. If so, please explain:
20a. Have any of these injuries required surgery? If so, please explain in 20b.*
No
Yes

20b. Please explain surgeries

Allergies/Medications

21a. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

21b. If you have alergies, please list them, along with their severity and current treatment plan:
22. Are you allergic to any medications?*
No
Yes
23a. Are you currently taking any medications?*
No
Yes

23b. What is the medication dosage and schedule?
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes
27a. Do you have any other physical, medical, or psychological conditions not listed above? Please list them in 27b.*
No
Yes

27b. Please list the conditions here.

Fitness

28a. Do you exercise regularly?*
No
Yes

28b. How often?

28c. If you have any fitness restrictions, please list them here.

28d. Duration/Distance:
28e. Intensity Level:*
Easy
Moderate
Competitive
29a. Do you smoke?*
No
Yes

29b. If you smoke, how much?
30. Swimming ability:*
Swimmer
Non-swimmer

Diet


31. Please list any dietary restrictions or food allergies. Are you vegetarian, vegan, gluten-free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when exposed to the allergen?
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Health History

Do you currently have or have a general medical history of:

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you marked "YES" on any of the above General Medical History questions, please provide a brief description of your condition and any associated physical limitations:

Do you currently have or have a history of any of the following Musculoskeletal Injuries:

19a. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones (including sprains)? If so, please explain in 19b.*
No
Yes

19b. If so, please explain:
20a. Have any of these injuries required surgery? If so, please explain in 20b.*
No
Yes

20b. Please explain surgeries

Allergies/Medications

21a. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

21b. If you have alergies, please list them, along with their severity and current treatment plan:
22. Are you allergic to any medications?*
No
Yes
23a. Are you currently taking any medications?*
No
Yes

23b. What is the medication dosage and schedule?
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes
27a. Do you have any other physical, medical, or psychological conditions not listed above? Please list them in 27b.*
No
Yes

27b. Please list the conditions here.

Fitness

28a. Do you exercise regularly?*
No
Yes

28b. How often?

28c. If you have any fitness restrictions, please list them here.

28d. Duration/Distance:
28e. Intensity Level:*
Easy
Moderate
Competitive
29a. Do you smoke?*
No
Yes

29b. If you smoke, how much?
30. Swimming ability:*
Swimmer
Non-swimmer

Diet


31. Please list any dietary restrictions or food allergies. Are you vegetarian, vegan, gluten-free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when exposed to the allergen?
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Health History

Do you currently have or have a general medical history of:

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you marked "YES" on any of the above General Medical History questions, please provide a brief description of your condition and any associated physical limitations:

Do you currently have or have a history of any of the following Musculoskeletal Injuries:

19a. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones (including sprains)? If so, please explain in 19b.*
No
Yes

19b. If so, please explain:
20a. Have any of these injuries required surgery? If so, please explain in 20b.*
No
Yes

20b. Please explain surgeries

Allergies/Medications

21a. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

21b. If you have alergies, please list them, along with their severity and current treatment plan:
22. Are you allergic to any medications?*
No
Yes
23a. Are you currently taking any medications?*
No
Yes

23b. What is the medication dosage and schedule?
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes
27a. Do you have any other physical, medical, or psychological conditions not listed above? Please list them in 27b.*
No
Yes

27b. Please list the conditions here.

Fitness

28a. Do you exercise regularly?*
No
Yes

28b. How often?

28c. If you have any fitness restrictions, please list them here.

28d. Duration/Distance:
28e. Intensity Level:*
Easy
Moderate
Competitive
29a. Do you smoke?*
No
Yes

29b. If you smoke, how much?
30. Swimming ability:*
Swimmer
Non-swimmer

Diet


31. Please list any dietary restrictions or food allergies. Are you vegetarian, vegan, gluten-free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when exposed to the allergen?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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