Safarat Pre-Travel Form

  • Safarat Pre-Travel Form

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  • Date of Birth*
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  • Expiry date of Passport
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  • Do you hold any other passports or 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?*
  • Do you have any medical concerns that you would like to raise with the trip's organisers before the trip?*
  • Have you ever had lung/respiratory problems (e.g. asthma, COPD, pneumonia, TB, pulmonary embolism (PE), lung surgery, collapsed lungs)?*
  • Have you ever had heart/cardiac/blood vessel problems (e.g. high blood pressure, angina, heart attack, deep vein thrombosis (DVT), heart surgery)?*
  • Have you ever had abdominal/bowel problems (e.g. hernias, stomach ulcers, reflux, inflammatory bowel disease, abdominal surgery, constipation, diarrhoea)?*
  • Have you ever had brain/nerve problems (e.g. epilepsy, seizure, severe headaches, migraines, sciatica, carpel tunnel syndrome, reduced sensation, brain surgery)?*
  • Have you ever had brain/nerve problems (e.g. epilepsy, seizure, severe headaches, migraines, sciatica, carpel tunnel syndrome, reduced sensation, brain surgery)?*
  • Have you ever had kidney/urinary/liver problems (e.g. recurrent cystitis, renal failure, liver failure, jaundice, hepatitis, pyelonephritis)?*
  • Have you ever had hormone/endocrine problems (e.g. diabetes, thyroid problems)?*
  • Have you ever had psychiatric/psychological problems (e.g. depression, schizophrenia, bipolar disorder, psychosis, overdose, self-harm, eating disorder)?*
  • Have you ever had altitude problems (e.g. acute mountain sickness (AMS), high altitude cerebral oedema (HACE), high altitude pulmonary oedema (HAPE))?*
  • 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?*
  • Do you have any tattoos or significant scars on your body?*
  • Current Immunisations:

  • 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.

  • Are you a smoker ?*
  • Do you have any known medical or other allergies?*
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  • 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).
     

  • Have you already purchased a medical and evacuation insurance policy?*
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