Health & Lifestyle Form

Thank you for taking the time to complete this form.

Your thorough and complete answers are important to help make the trip as enjoyable as possible and to help us more
effectively manage the risks involved with adventurous activities in remote areas.

All information that you submit will be used only by Exposure staff for pre-trip screening and to advise your guides
of any relevant conditions. We may also share this information with other medical providers in an emergency situation.

This information will not allow us to fully determine if your condition is appropriate for the Exposure trip, you should consult your
doctor if you have concerns about your suitability for the challenges of the Exposure trip.

This form will ask you for the following information:

• Your Health History
• Any Medications
• Any Allergies
• Any Dietary restrictions
• Your general Lifestyle background
• Emergency Contact Information for 2 individuals (address and phone numbers)
• Health Insurance Information (Insurer, policy number, contact number(s)

Last Name: First Name:

Email: DOB (mm/dd/yy):

HISTORY

Please explain any items checked above:

MEDICATIONS

It is very important that we have complete information about any medications before your trip so that we can plan appropriately.
Most medications can be managed in the field. Bring extra medications and store in seperate places. It may be difficult
or impossible to replace prescription meds during the trip

If yes, please describe the condition you are treating, product and dosage:

If yes, please describe the condition you are treating, product and dosage:

ALLERGIES

Please advise us of any allergies that you may have. If you have an analphylactic reactions to insect bites or stings,
it is your responsibility to bring your own adrenaline kit.

Are you allergic to ANY medications? Yes No

If yes, please list:

Do you have any other allergies? Yes No

If yes, please explain:

Are you allergic to bee stings? Yes No

If yes, do you carry an adrenaline kit? What type?:

Are you receiving "allergy shots"? Yes No

If yes, please give details:

Are any of your allergies analphylactic? Yes No

If yes, please explain:

DIET

Do you follow a special diet? Yes No

If yes, please explain:

Do you restrict certain foods from your diet for health reasons, religious belief, personal preference etc.? Yes No

If yes, please explain which foods and reasons:

Do you have concerns about access to certain foods during the trip? Yes No

If yes, please explain:

How many glasses of water (8 oz.) do you drink in a typical day?

How many glasses of caffeinated beverages do you drink in a typical day?

Coffee Tea Soft drinks

How many glasses of alcoholic beverages do you drink in a typical day?

Beer Wine Liquor

LIFESTYLE

If you smoke, do you tend to need antibiotics for treatment of respiratory infection Yes No

Are you bothered by tobacco smoke? Yes No

Please describe your participation in outdoor activities; what activity, how often and at what level (beginner, social, competitive, way of life..):

Please describe your current level of fitness:

EMERGENCY CONTACT INFORMATION

Please provide complete details. Include telephone area codes as well as country/city codes if outside the US.

Primary emergency contact: (please do not include someone else on this Exposure trip)
Name:
Relationship:

Address:

Home Phone:
Work Phone:
Cell Phone:

Secondary emergency contact: (please do not include someone else on this Exposure trip)
Name:
Relationship:

Address:

Home Phone:
Work Phone:
Cell Phone:

Health Insurance Information (you are responsible for the costs of any and all medical care and evacuation)

Health Insurance Company:
Policy Number:

Contact Number:
Secondary Contact Number:

SUBMIT THIS FORM