Medical Questionnaire

 Medical Questionnaire for ACSP Peru Expedition 2015

All information will be kept strictly confidential. 

Return file via email to:  [email protected]

YOU CAN DOWNLOAD A COPY OF THIS FORM HERE.2015_peru_medical_questionnaire.docx

  See your primary care doctor and/or specialist medical provider prior to departure for a physical exam, blood work, and any other medical work up and procedures deemed appropriate by your physician to assure proper health and preparation for the expedition and travel.

 You are required to have at minimum your own supplies of the following 4 medications prior to arrival in Peru:

  1. 1.      Acetazolamide 125mg, twice per day  (for altitude illness prevention and treatment)
  • Please note, you are not required to use Acetazolamide, but you are required to have it with you incase you become ill. 
  1. 2.      Ciprofloxacin 500mg, twice per day  (for travellers diarrhea)
  2. 3.      Ibuprofen 200mg, four to six times per day  (for aches and pains, High Altitude Headaches, fevers…)
  3. 4.      All of your regular daily medications.

 Climber Name

Climber Age

Climber Gender

Profession:

Emergency Contacts    Name: 

                                    Phone Number: 

                                    Relationship: 

 Name: 

                                    Phone Number: 

                                    Relationship: 

 What medical training experience do you have (First Aid, EMS, nurse…):

 If you die during the climb, do you want your body brought back to the US (if possible) or left on the mountain?

Altitude Experience

What is the highest altitude you have climbed:

Have you ever experienced altitude related illness: 

If YES, please describe in detail at what altitude it occurred, what were your symptoms, and how did you manage it. 

 Will you be using altitude medications for altitude prophylaxis, such as acetazolamide, herbals etc:

Past Medical History

List any allergies that you are aware of, such as medications or bee-stings: 

(For medication allergies include what kind of reaction you get, such as a rash, swelling and difficulty breathing.)

 If you do have any allergies, do you or have you ever required Epinephrine, or an EpiPen:

 Do you have an allergy to Sulfa Drugs:

List all of your medications, including quantities (mg) and frequencies:  (Example:  Hydrochlorothiazide 25mg, once per day.)

List all Medical Problems:  (Example:  Hypertension.)

List all Surgeries you have had in the past, including year:  (Example:  appendectomy 2010.)

Have you ever had any of the following problems?  (Please indicate YES or NO for each question.  If YES, please explain.)

Heart Problems:  (Heart murmur, heart attack, angina, dysrhythmia such as Atrial Fibrillation…)

Breathing or Lung Problems:

Have you ever smoked:  (If YES, how much?)

Muscular or Joint Problems:

Kidney Problems

Urinary Problems

Liver Problems:

Intestinal Problems:

Seizures:

Psychiatric Illness:

Blood or Immune Disorders:

Do you require Vision Correction:  (If YES, indicate contact lenses, glasses.)

Have you had corrective eye surgery: 

Have you had any medical problems that do not fit into any of the above categories:

Vaccinations

Note, it is recommended that you see your primary care doctor or a Travel Medicine specialist prior to departure for additional booster shots and up to date information pertinent to travel in Peru. Also visit the CDC website for the most up to date recommendations:  http://wwwnc.cdc.gov/travel/destinations/traveler/none/peru

Which year was your last vaccination or booster shot for the following?

Tetanus Booster Shot: 

Measles/Mumps/Rubella: 

Diphtheria/Pertussis/Tetanus (DPT): 

Polio: 

Hepatitis A:

Hepatitis B: 

Meningococcal: 

Typhoid:

Yellow Fever:

Any other vaccinations: 

If there is anything else you would like to add about your medical health or wishes, please do so here:

Medical Release Form

In consideration of being permitted to participate in any way in the Climber Science Program Peru Expedition of 2014 I, for myself, my personal representatives, assigns, heirs, and next of kin:

1. Acknowledge, agree, and represent that I understand the nature of the Activity to include, but are not limited to, the following: rockfall; icefall; avalanches; mountain storms; wind; snow; ice; hail; falling; slipping; objects that may fall from above; unstable or loose rocks, snow, and ice; uneven terrain; cold and hot temperatures; dehydration; high altitude related illnesses; elevation; exertion; illness; unavailability of immediate medical attention in the event of injury or ill health; equipment failure, including failure of medical equipment and supplies; use of equipment that is not medically approved for medical care; and that I am qualified, in good health, and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the conditions to be unsafe, I will immediately discontinue further participation in the Activity.

2. Fully understand that: (a) This activity involves risks and dangers of serious bodily injury, including permanent disability, paralysis, and death; (b) these risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Activity, the conditions in which the Activity takes place, the environment in which the Activity takes place, or the negligence of the Releasees named below; (c) any and all medical care and rescue efforts provided will be in austere environments with limited resources, and medical care and rescue efforts will be provided by no Board Certified nor licensed physician; (d) medical attention, treatment, and rescue may require use of medical techniques and equipment that are not recognized nor supported by medical literature (e) there may be other risks or social and economic losses either not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I incur as a result of my participation in the Activity.

3. Fully understand that I am responsible for all charges, costs, and expenses that may be incurred as a consequence of any rescue operations, evacuation activity (including, but not limited to, helicopter services), and provision of medical care, and specifically acknowledge that I shall be responsible for the payment of all such charges, costs, and expenses. This Release is intended by the Requesting Party to be full, complete, and without exception of any kind whatsoever.

4. State and acknowledge that if I want financial protection against the risks of injury associated with the activities I must obtain my own life, liability, accident, or health insurance at my own sole cost and expense to protect myself, my personal representatives, assigns, heirs, and next of kin. I specifically acknowledge that I am not requesting and do not anticipate that the Releasees provide such insurance coverage. I specifically acknowledge that I am responsible to obtain my own life, liability, accident, or health insurance at my own sole cost and expense if such insurance coverage is desired. I acknowledge that I am aware that the Releases will not provide, and is not providing, such insurance coverage.

5. Hereby release, discharge, and covenant not to sue now or in the future the sanctioning organization(s), their administrators, directors, agents, officers, medical providers, members, volunteers, and employees, other participants, officials, rescue personnel, sponsors, advertisers, owners and lessees of premises on which the Activity is conducted, (each of the forgoing shall be considered one of the Releasees herein) from all liability, claims, demands, losses, or damage on my account caused, or alleged to be caused, in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations and medical care; and I further agree that if, despite this release and waiver of liability, assumption of risk, and indemnity agreement I, or anyone on my behalf, makes a claim now or in the future against any of the Releasees, I will indemnify, save, and hold harmless each of the Releasees from any litigation expenses, attorney fees, loss, liability, damage, or cost which may be incurred as the result of such claim.

I acknowledge that I am over the age of 18 years, have read this agreement and fully understand its terms, understand that I have given up substantial rights by signing it, have signed it freely and without any inducement or assurance of any nature, and I intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect.

Signature:

Date: 

Home Address: 

Email: 

Phone number: