KIlimanjaro Medical Survey

Kilimanjaro Medical Form

Climber's Information

First Name *

As it appears on your passport

Middle Name

As it appears on your passport

Last Name *

As it appears on your passport

Do you plan to purchase Travel Insurance? *

Travel Insurance Disclaimer *

I realize that it is my responsibility for any costs for loss of personal luggage, money, and goods, medical expenses, theft, damage or cancellation or curtailment of the adventure. I understand the I will be charged directly by the relevant service provider for any medical and emergency services I may require, including but not limited to helicopter evacuation, hospitalization, transportation and additional lodging.

Do you have any known allergies? *

Allergies

Medical Information

Please answer each of the following health questions by providing detailed information that includes dates and medical response. Please let us know of any changes!

Have you ever experienced any form of altitude sickness? *

Yes

No

Have you ever experienced any form of altitude sickness?

In the past two years, have you had any major accidents or illnesses? *

Yes

No

In the past two years, have you had any major accidents or illnesses?

Do you have any physical limitations or medical conditions that might restrict your full participation in this trek? *

Yes

No

Do you have any physical limitations or medical conditions that might restrict your full participation in this trek?

Do you have any knee problems? *

Yes

No

Do you have any knee problems?

Will you be taking any medications during this trip? *

Yes

No

Will you be taking any medications during this trip?

Personal and Group Medications: Barking Zebra Adventures advises that I obtain and carry any personal medications with a quantity sufficient for the duration of the trip and speak with my personal physician about specific medications for possible altitude-related medical conditions. The medications to discuss with your personal physician include but are not limited to ibuprofen, anti-emetics, acetazolamide, and dexamethasone for acute mountain sickness (AMS), high-altitude pulmonary edema (HAPE), or high-altitude cerebral edema (HACE). (Trekking guides will carry a very limited supply of medications and oxygen to be used only in a medical emergency.)

ADDITIONAL COMMENTS:

Signature *

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