VITAL Health & Lifestyle Form

VITAL Health & Lifestyle Form

Participation Information
**Privacy & Confidentiality**

All personal and medical information collected on this form will be kept confidential and onlys hared with VITAL Ventures staff or emergency personnel if necessary to ensure your safety and wellbeing during your participation in VITAL activities. This form is used solely to support safe and informed participation in adventure experiences.
Full Name:
Date of Birth:

MonthDayYear
Date
Age:
Gender:
Height:
Weight:
Phone Number:
Email Address:
example@example.com
Mailing Address:
Emergency Contact Name:
Relationship:
Phone Number
Medical Information & History
1. General Health
How would you describe your present state of health?

ExcellentGoodFairPoor
Do you have any medical conditions that might affect your participation?

YesNo
If Yes please specify:
Have you been hospitalized or required medical care in the last 5 years?

YesNo
If Yes please provide details:
Are you currently under a physician's care for any medical condition?

YesNo
2. Medical Conditions
Check all that apply:

Heart DiseaseHigh Blood PressureDiabetesAsthmaAllergiesEpilepsyArthritisOsteoprosisRespiratory ConditionsStrokeGastrointestinal IssuesThyroid ConditionsAnxiety/DepressionAutoimmune DisorderOther
If not listed, please list all below:
3. Medications & Allergies
Do you take any medications that would be important for us to be aware of in the event of an emergency?

YesNo
If Yes list all medications dosage and frequency:
Do you have any allergies?

YesNo
If Yes specify allergens (medications foods insects environmental etc.) and severity:
Do you have a prescription for, and carry, an EPI Pen?

YesNo
4. Surgical & Injury History
Have you had any major surgeries that may impact your ability to participate?

YesNo
If Yes describe:
Have you had any past injuries that may affect your activity level?

YesNo
If Yes describe:
5. Physical Fitness & Activity Level
Do you engage in regular physical activity?

YesNo, but intend to prepare for this adventure.
If Yes describe type & frequency:
What is your primary fitness goal for this trip?

EnduranceStrengthAdventureGeneral Fitness
6. Dietary & Nutrition Information
Do you follow any specific diet?

Gluten-FreeVegetarianVeganDairy-FreeOther
If other please specify:
Do you have any hydration concerns (e.g., history of dehydration, kidney issues)?

YesNo
If Yes please describe:
7. Insurance & Emergency Care Information

This information is optional and will only be used in an emergency (e.g., evacuation support). This information is securely stored and only accessed if and when needed. If you do not want to disclose, please carry a physical copy on you during the entire event and provide a copy to your emergency contact.
1. Medical Insurance Provider:
Policy Number:
Insurance Contact Phone Number:
2. Primary Care Physician Name:
Contact Phone Number:
3. Do you have medical evacuation insurance?

YesNo
If Yes, Company Name:
Phone Number:
4. Authorization for Emergency Medical Care

In the event of an emergency, I authorize VITAL Ventures and medical personnel to provide necessary care.
Participant Signature:

Clear
Date:

MonthDayYear
Date
Physician’s Release Requirement

If you answered "Yes" to any of the questions regarding medical conditions, surgeries, or physical concerns, you are required to provide a signed physician’s release to ensure your participation in the upcoming adventure.

Please have your physician review your health information and confirm that you are cleared for physical activity related to this program. This signed release is required for all individuals who answer "Yes" to any medical-related question.
Assumption of Risk & Liability Waiver

I understand that adventure travel involves risks, including but not limited to injuries, altitude sickness, and exposure to unpredictable environmental conditions.

I certify that all information provided is accurate and complete.

I accept full responsibility for my health and participation.
I agree to the terms and conditions outlined in this assessment.

Yes
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

VITAL Health & Lifestyle Form

Medical Information & History