Name____________________________________________________________
Height_______Weight________Sex_____Age_____Shoe Size_____

General Physical Condition
_____Have daily aerobic exercise routine. Do not get winded walking up 3 flights of stairs. Participate in active sports.
_____Have irregular exercise routine. Slightly winded after 3 flights of stairs.
_____Do not do any regular exercise.
_____No regular Exercise. Some medical problems.

Do you have any of the following?
Fear of Heights?__________________Details___________________________________
History of Heart Problems?__________Details__________________________________
History of Diabetes?_______________Details___________________________________
History of Seizures?_______________Details___________________________________
History of Infectious Disease?________Details__________________________________
Last Blood Pressure reading___________________Date__________________________
Previous injury or ailment that may give you trouble occasionally? __________________

Please list any allergies and whether your reactions are severe or moderate.
Medicines____________________ ____________________________________
Bees_________________________ ____________________________________
Insects_______________________ ____________________________________
Foods________________________ ____________________________________
Plants________________________ ___________________________________
Other___________________________ _________________________________

List medications taken on a regular basis._______________________________________
And what condition does the medication treat? __________________________________
Any dietary restrictions?____________________________________________________
Are you Pregnant?_______If so how long?____________
Your doctor’s name, and phone number_______________________________________

The purpose of this questionnaire is to make sure you have selected a trip that is appropriate for you. All the information is confidential. We will not contact anyone or your doctor without first talking to you. If there is some reason we feel you have selected a trip inappropriate for you, we will discuss this with you. Thanks for your patience.