Safarat Pre-Travel Form

Safarat Pre-Travel Form
Full Name*

First NameMiddle NameLast Name
Email Address*
example@example.com
Telephone Number*

Dial CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

DayMonthYear
Date
Gender:*
What is your age?*
Passport Copy:*

Please upload a clear copy of your passport including both pages
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Passport Photo:*

Please upload a clear passport photo of you
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Nationality*
Passport Number*
Expiry date of Passport

DayMonthYear
Date
Occupation*
Height*
Eye Colour:*
Have you visited Afghanistan before?*
please list all prior trips and the purpose of your previous travel to Afghanistan.
Do you hold any other passports or citizenships?*

YesNo
Please give more information here of your additional passports/citizenships:
Collecting medical information from expedition participants enables expedition organisers to prepare a suitable medical kit and guides medical decisions in the field. The information you provide will be kept confidentially by the Safarāt team; please complete it fully and honestly.

Please be aware that failure to disclose a medical condition can invalidate insurance and prevent evacuation and repatriation.
Are you currently taking any medication?*

YesNo
Please list them your current medications and doses and at which frequencies.
Please make sure you have an ample supply of your prescribed medication in Afghanistan. Specialist medicines are difficult to buy in the country and the quality is often an unknown - please make sure to bring a copy of your prescription with you if you are bringing medicines into the country with you. You will also require this prescription if you need to buy more medicine for some reason in the country - the Taliban have cracked down hard on the purchase of many medicines including some antibiotics without a doctor's note! We are consistently shocked at the specialist medicine that our travellers forget to bring with them to Afghanistan!!
Do you have any medical concerns that you would like to raise with the trip's organisers before the trip?*

YesNo
Please give more details on your medical concerns:
Have you ever had lung/respiratory problems (e.g. asthma, COPD, pneumonia, TB, pulmonary embolism (PE), lung surgery, collapsed lungs)?*

YesNo
Please give more details:
Have you ever had heart/cardiac/blood vessel problems (e.g. high blood pressure, angina, heart attack, deep vein thrombosis (DVT), heart surgery)?*

YesNo
Please give more details:
Have you ever had abdominal/bowel problems (e.g. hernias, stomach ulcers, reflux, inflammatory bowel disease, abdominal surgery, constipation, diarrhoea)?*

YesNo
Please give more details:
Have you ever had brain/nerve problems (e.g. epilepsy, seizure, severe headaches, migraines, sciatica, carpel tunnel syndrome, reduced sensation, brain surgery)?*

YesNo
Please give more details:
Have you ever had brain/nerve problems (e.g. epilepsy, seizure, severe headaches, migraines, sciatica, carpel tunnel syndrome, reduced sensation, brain surgery)?*

YesNo
Please give more details:
Have you ever had kidney/urinary/liver problems (e.g. recurrent cystitis, renal failure, liver failure, jaundice, hepatitis, pyelonephritis)?*

YesNo
Please give more details:
Have you ever had hormone/endocrine problems (e.g. diabetes, thyroid problems)?*

YesNo
Please give more details:
Have you ever had psychiatric/psychological problems (e.g. depression, schizophrenia, bipolar disorder, psychosis, overdose, self-harm, eating disorder)?*

YesNo
Please give more details:
Have you ever had altitude problems (e.g. acute mountain sickness (AMS), high altitude cerebral oedema (HACE), high altitude pulmonary oedema (HAPE))?*

YesNo
Please give more details:
Have you ever suffered from a medical condition that you have not mentioned above requiring admission to hospital, long-term treatment or surgery? Have you ever suffered from a medical condition that you have not mentioned above requiring admission to hospital, long-term treatment or surgery?*

YesNo
Please give more details:
Do you have any tattoos or significant scars on your body?*

YesNo
Please give more details:
Current Immunisations:

DiphtheriaPolioTetanusHepatitis AHepatitis BMeningococcal MeningitisRabiesJapanese EncephalitisTuberculosisTyphoidYellow FeverCholera
Please note it is the travellers responsibility to ensure recommended immunisations are up to date - Afghanistan is a place where diseases such as Poliio and Hepatits are still common killers.

It is imperative that you check in with your doctor and make a decision on what immunisations are appropriate to you.

On some of our trips we may visit places where there are rabies carrying bats and street dogs in Afghanistan commonly carry the disease. We reccomend our travellers are protected against the deadly disease.
What is your blood type?
Are you a smoker ?*

YesNo
How would you rate your overall physical health?*
Do you have any known medical or other allergies?*

YesNo
Please list them.
Emergency Contact*

PrefixFirst NameLast Name
Dial CodePhone Number
example@example.com
Location of your Emergency Contact*
e.g. London, UK
Relationship to you:*
Declaration

·        I agree that the above information is true and accurate to the best of my knowledge.

·        As far as I am aware I am medically fit to partake in a remote expedition which will be both physically and mentally demanding and potentially include exposure to extremes of heat, cold and altitude.

·        I understand that I am responsible for providing all my normal medications and supplies for the treatment of my pre-existing medical conditions for the duration of the expedition.

·        I understand that my medical information will be kept confidential and every effort will be made to consult me beforehand should any disclosures be deemed necessary.

·        I agree that should I become incapable of giving consent for disclosure of essential medical information in the event of an emergency, information may be imparted at the discretion of the medical team acting in my best interests.

·        I agree to discuss/disclose to the organisers any injury or illness occurring between this date and the date of departure.

·        I have made a copy of this completed form for my personal records (a copy of this form will be emailed to you upon submission).
Signature

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Do you speak any other languages and to what level?*
Flight Arrival and Departure details if currently known including flight numbers:
Please leave blank if you are travelling with Safarāt as part of a group with a third party travel agent or company. They will do the hard work for you and let us know when you are arriving and departing!
Have you already purchased a medical and evacuation insurance policy?*

YesNo
Who is your insurance provider?
Please upload a copy of your insurance documents here.

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