Full Name *
Age *
Date of birth *
E-mail *
Address *
City *
State *
Postal Code *
Country *
Height *
Weight *
Profession
Phone Number *
Passport Number *
Emergency contact *
Relation *
Phone Number *
Work phone
Medical Insurance *
Policy Number *
I can jog without distress * I can jog without distress* 1 mile 3 miles 5 miles more
I can easily walk with a day pack over * I can easily walk with a day pack over* 4 hrs 8 hrs 12 hrs more
I regularly engage in the following sports/fitness training programs
Sickness or injuries in the last 12 months
Please list medications taken regularly or intermittently and reason
Thank you for marking with an X in the adequate column. If the answer is Yes, thanks for giving complementary information on the other side of the sheet. Have you or have you had any of the following pathologies or lesions:
Allergies * Allergies* Yes No
If your answer is yes, please list on the other side. Include allergies to insect bites, plants, food and/or medicine.
Significant column, ankle, knee, shoulder or arm lesion * Significant column, ankle, knee, shoulder or arm lesion* Yes No
Frost bites * Frost bites* Yes No
Pulmonary or cerebral edema * Pulmonary or cerebral edema* Yes No
Respiratory problems or asthma * Respiratory problems or asthma* Yes No
Diabetes * Diabetes* Yes No
Cardiac diseases * Cardiac diseases* Yes No
Epilepsy * Epilepsy* Yes No
Convulsions * Convulsions * Yes No
If yes, what was the cause?
Gastro intestinal problems * Gastro intestinal problems* Yes No
Blood diseases * Blood diseases* Yes No
High Blood pressure * High Blood pressure* Yes No
Hepatitis or other liver diseases * Hepatitis or other liver diseases* Yes No
Are you under a medical treatment? * Are you under a medical treatment?* Yes No
Are you taking any medicine? Which one? What are its secondary effects?
Is there any other thing that can affect you physical condition?
Last tetanus vaccination
Food restrictions?
Are you pregnant? Are you pregnant? Yes No
How would you describe you state and health?
Any allergic person must bring their own medicine with an extra doze and must be able to self administrate it.
I declare that the information here provided is fair and true. *