MGO Rocky Mountain Expedition Medical Form Participant's Name(Required) First Last Participant's Age(Required)Please enter a number greater than or equal to 16.Participant's Date of Birth Month Day Year Participant's Gender(Required) Male Female Participant Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country(Required)Please SelectUnited StatesCanadaBermudaGuam MicronesiaOtherEmail(Required) Enter Email Confirm Email Mobile Phone(Required)Home PhoneParticipant Height & WeightHeightWeightParticipant Blood Pressure and Resting Heart Rate(Required)Blood Pressure (#/#)Resting Heart Rate (bpm)Primary Emergency Contact(Required)NameRelationshipPrimary Emergency Contact Phone Numbers(Required)MobileHomeWorkSecondary Emergency Contact(Required)NameRelationshipSecondary Emergency Contact Phone Numbers(Required)MobileHomeWorkEvacuation and Medical InsuranceWe strongly encourage you to have medical and evacuation insurance and to bring your insurance card or other documentation with you on the MGO Expedition.Evacuation InsuranceCompany NamePolicy #Contact PhoneCoverage Amount ($)Medical InsuranceCompany NamePolicy #Contact PhoneParticipant's Allergies No allergies Yes, Participant has allergies AllergiesAllergyReactionMedication Required Add RemoveClick on (+) sign after field to add additional allergies.Participant's Medications No medications Yes, Participant has medications MedicationsMedication NameDosageFrequencySide effects (Known/Potential)Reason for Taking Add RemoveClick on (+) sign after field to add additional medications.General Medical HistoryPlease answer the following medical history questions. If answering YES, use the details field to explain history in more detail. Do you currently have, or have a history with, the following conditions:Respiratory problems, Asthma, Do you smoke?(Required) Yes No Details (Respiratory problems, Asthma, Do you smoke?) Diabetes(Required) Yes No Details (Diabetes) Gastrointestinal problems(Required) Yes No Details (Gastrointestinal problems) Cardiac problems, Hypertension(Required) Yes No Details (Cardiac problems, Hypertension) Neurological problems, Seizures(Required) Yes No Details (Neurological problems, Seizures) Vision or Eye problems(Required) Yes No Details (Vision or Eye problems) Hearing problems(Required) Yes No Details (Hearing problems) Bone, Joint, Muscle Problems(Required) Yes No Details (Bone, Joint, Muscle Problems) Head trauma, Traumatic Brain Injury(Required) Yes No Details (Head trauma, Traumatic Brain Injury) HiddenSubstance Abuse, Anxiety, Depression(Required) Yes No HiddenDetails (Substance Abuse, Anxiety, Depression) Have you had a recent illness within the last 12 months?(Required) Yes No Details (recent illness) Have you had surgery or been hospitalized in the last year?(Required) Yes No Details (surgery/hospitalized) Have you ever had problems related to exposure with altitude?(Required) Yes No Details (altitude issues) If female, are you pregnant? Yes No Any other Health complaint or medical issue that would affect your participation on this MGO Expedition?(Required) Yes No Details (other health/medical issue) Date of last tetanus immunization:(Required) Month Day Year In short, describe your swimming ability(Required)Date of most recent physical:(Required) Month Day Year Physician Information(Required)Physician's NamePhysician's AddressPhysician's PhoneAcknowledgement:(Required) I acknowledge the below information.The information provided here is a complete and accurate statement of any physical and psychological conditions that may affect the Participant on this MGO Expedition. I realize that failure to disclose such information about Participant could result in serious harm to myself and other participants. I agree to inform the MGO Expedition leader should there be any changes to the Participant's health status prior to the start of the MGO Expedition. I understand the outing may require vigorous activity that is both physically and mentally demanding in isolated areas without medical facilities. The Participant is fully capable of participating on this MGO Expedition.Adult Participant / Parent or Guardian Signature Reset signature Signature locked. Reset to sign again HiddenDate MM slash DD slash YYYY To reveal submit button, what is 6+6?(Required) 0 16 12 CommentsThis field is for validation purposes and should be left unchanged. Go ahead and share:Click to share on Facebook (Opens in new window)Click to share on Twitter (Opens in new window)Click to share on WhatsApp (Opens in new window)Click to print (Opens in new window)
