Microsoft word - ani mif 2009.doc

C O N F I D E N T I A L
Medical Information Form 2009
You must complete this Medical Information Form in full before we will accept your booking. How we use the information:
Your answers will provide our Medical Officers at Patriot Hills Camp with essential information to make any
necessary, special preparations and to provide you with as good medical care as we can in Antarctica if
required. To this end, if you answer “Yes” to any question please give the fullest possible details. Who sees the information:
Our administrative staff will receive and forward your information to the ANI Chief Medical Officer for review.
All information received is confidential, and securely stored. However, any or all of it may be shared with your
guide, other company personnel or third parties, if this is deemed necessary for the safety or well-being of you FAMILY or SURNAME: .GIVEN NAMES:
PROGRAM NAME:
PROGRAM DATE
. (Day/Month/Year): .
Your Height (cm):
. Weight (kg):
Date of Birth
dd/mm/yy:

Past Medical Conditions
Have you had any significant medical, surgical or mental health conditions? Present Medical Conditions
Do you have any physical or mental health conditions requiring treatment or 4376 South 700 East, Suite 226, Salt Lake City UT 84107-3006 USA Tel: +1 801-266-4876/4982 Fax: +1 801-266-1592 general@adventure-network.com Web: www.adventure-network.com Have you undergone any surgical procedure in the last year? Have you had any hospital investigations or treatment in the last year? Medication
Are you taking any drugs or other medication, including anti-coagulants, or Allergies
If YES, please give details What are you allergic to? Mild/Moderate/Severe Do you have, or have you ever had:
If YES to any of the above, please give full details (continue on extra pages if necessary) Disabilities
Do you have any physical limitations or disabilities? Do you use any artificial aids, e.g. wheelchair, stick, prosthetic If YES to any of the above, please give full details The following sections are for different programs. You need only complete the relevant section for
your particular Program
Vinson, Ski Last Degree, Ski South Pole, Ski Safari and Marathon Programs, and All Expeditions
What is the highest altitude you have ever
climbed to? .was this? .
What is the highest altitude you have climbed to in the past 3 years? .
Do you intend to use Diamox (acetazolamide), e.g. on your ascent? Have you ever had altitude illness (AMS/HAPE/HACE)? If YES, please give details At what altitude were you ill? Did you take or receive any drugs or other medical treatment? Did you need to descend? If so, how far did you descend until you recovered? Have you ever had frostbite or other cold injury? South Pole Flights, Emperor Penguins and Antarctic Odyssey Programs
Do you have difficulty or get out of breath climbing 20 steps? Do you have difficulty climbing a step-ladder? Do you have any difficulties getting dressed or tying boot laces? Do you have any special personal hygiene requirements? Are there any daily living tasks that you are unable to perform? Do you have difficulty walking over uneven ground? Do you do any regular physical activity? How far you can comfortably walk on level ground without stopping? If YES to any of the above, please give full details (continue on extra pages if necessary) For All Programs and All Expeditions
If you have any medical issues that may affect your fitness to participate you are advised to seek advice from
your own physician. The ANI Medical Officer is freely available to discuss any issues you have concerning your health in Antarctica. Details of your personal Physician

Please sign below. Your signature confirms—
that you have read your program guidelines and are fit to undertake your chosen expedition; that you have provided accurate and complete information; your consent for ANI to seek further medical information from your personal Physician; that you will inform ANI of any change in your medical details prior to the start of your that you agree to undergo a medical examination if required by ANI either before or during the right of ANI to adapt or curtail your program due to medical circumstances.

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