Name *

Email Address *

Your Tour *

Tour Dates *

Date of Birth *

dd/mm/yyyy

Gender *

MaleFemale

Prinicipal Health Care Plan

Prinicipal Health Care Plan #

Extended Insurance

Extended Insurance #

Your Doctor's Name

Doctor's Phone Number

Emergency Contact

Emergency Contact Phone

Emergency Contact Relation

Allergies *

Please list any allergies, including food allergies (not preferences), bug bites, medications etc. Put none if no allergies.

Medications

Please list any medications you are taking, including prescription, non-prescription and nutritional supplements.

Last Tetanus Immunization

Your Health

Please describe your overall health as well as you can.

Chronic Conditions

Do you see a Doctor regularly for any chronic conditions? If yes, please explain.

Past Surgeries, Injuries, Hospitalizations

Please list any past surgeries, significant injuries and hospitalizations.

If Female, Are You Pregnant?

YesNo

Please Check All That Apply

Please describe below.

Cardiac DiseaseDiabetesStrokeSeizuresHigh Blood PressureGastro-Intestinal DiseaseLung DiseaseKidney ProblemsLiver ProblemsCancerThyroid ProblemsMigrainesMusculoskeletal ProblemsAbnormal Bleeding, Blood ProblemsMental Health Disorders

Please Describe Any Above Conditions

Have You Ever Experienced Cardiac Arrest or Heart Attack

YesNo

Please Rate Your Fitness

1- 10 ( 10 being a super athlete)

—Please choose an option—1-3 (I don't hike or bike)3-5 (I hike once a week)5-7 (I hike bike exercise 3-4 times a week)7-9 (Exercising is part of my everyday)10 (I am super fit)

Please Rate Your Swimming Ability

—Please choose an option—Help!Doggy PaddlerStrong swimmer

Physical Limitations

Would you or you Doctor say you have any significant physical limitations?

Anything Else That May Help Us?

Feel free to tell us anything else you feel might help.

Diet

Please describe any dietary restrictions. We will do our best to suit your needs. Feel free to include your favourite kind of foods.

I have read and agreed to Yoho AdventuresTERMS & CONDITIONS