BRW Medical Form

General Medical History
Please answer the following medical history questions. If answering YES and you need to include more detail, use a separate sheet and email to contact@bigroundworld. Please include your name on the extra sheet.
Do you currently have or have had a history with any of the following conditions?

Bone joint or muscle problems?*

YESNO

Additional information

Head trauma, traumatic brain injury?*

YESNO

Additional information

Neurological problems, seizures?*

YESNO

Additional information

Cardiac issues, hypertension?*

YESNO

Additional information

Respiratory issues, asthma?*

YESNO

Additional information

Gastrointestinal issues?*

YESNO

Additional information

Diabetes?*

YESNO

Additional information

Do you wear Rx eye glasses? Please describe any eye issues.*

YESNO

Additional information

Hearing issues. Do you use hearing aids?*

YESNO

Additional information

Are you going through any life transitions?*

YESNO

Additional information

Are you a smoker?*

YESNO

Any illnesses in the last 12-24 months requiring physician attention?*

YESNO

Have you had any surgery or been hospitalized in the last 12-24 months?*

YESNO

If applicable, any problems related to exposure to altitude?*

YESNO

Any other health complaints or medical issues that would affect your participation on this trip?*

YESNO

If YES, please explain.

Date of last tetanus immunization*

Date

Date of most recent physical*

Date

Physician's Name*

Physician's Office Address*

Phone*

If required by your trip leader to obtain a physical prior to your trip, please print out this form and have your physician sign and date and resubmit to Big Round World.

The information provided here is a complete and accurate statement of any physical and psychological conditions that may affect my participation on this trip. I realize that failure to disclose such information could result in serious harm to myself and other participants. I agree to inform my trip leader should there be any changes to my health status prior to the start of the trip. I understand the trip may require vigorous activity that is both physically and mentally demanding in isolated areas without medical facilities. I am fully capable of participating on this trip.

Trip title*

Trip Dates*

mm/dd/yyyy to mm/dd/yyyy

Participant signature*

Clear

To apply your signature use your finger (touch screen device) or mouse (non-touch screen) to write your name.

Date form completed*

Date

Please verify that you are human*

Medical Form

Travel Insurance

Passport Information