Confidential Medical Information

The submission of this completed form constitutes an agreement between you and Icetrek Expeditions that all of the information provided is true and not intended to mislead Icetrek or misrepresent you. All fields are mandatory. Write No or NONE if any medical conditions don't apply.

Name *

Email *

General health *

Height *

Weight *

Do you have any current or recurring medical problems? *

Are you taking any medication? *

Are you taking any medication? If so what, dosage and how often?

Have you had any surgeries? *

Have you had any surgeries? If so, what and when?

Do you have any food, medical or other allergies? *

Do you suffer unusually from Reynaud's Syndrome, chillblains, previous frostbite, sleep coldly. *

Do you have problems with vision or hearing? *

Do you have high blood pressure? *

If so what is your typical reading?

Do you have heart murmurs, episodes of irregular heartbeat, shortness of breath or chest pain on exertion? *

Do you have asthma? *

Do you have any other respiratory or cardio-vascular problems? *

Do you suffer from altitude ailments? *

Do you have any mental health issues? *

Fitness *

What is your daily or weekly fitness regime?

Do you require a special diet? *

Describe your dietary dislikes, intolerances and/or allergies

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Emergency Contact *

Name and phone number

Doctor contact details *

Name and phone number

Emergency Medical Evacuation Insurance *

List your insurer, policy number and their emergency phone number.

Emergency Medical Evacuation (Medevac) insurance is required for all North Pole and South Pole/Antarctic trips. Medevac insurance is not mandatory for our other trips however we strongly recommend it as an inclusion in your medical/travel policy.

Disclosure *

I realise that failure to disclose relevant information could result in serious harm to fellow participants and myself and agree to indemnify and hold Icetrek harmless if all relevant information is not disclosed

Statement *

The information provided above is a complete and accurate statement of the physical and psychological factors which may affect my participation on an Icetrek expedition or tour.

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Confidential Medical Information