Confidential Medical Questionnaire


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Our adventure tours are intended for participants in reasonably good health for the sake of their safety and the safety of others. We require that you complete all questions fully and truthfully. The information you provide is important, and potentially critical, in the event of a medical emergency.

We reserve the right to decline to allow your participation on our tour due to medical reasons. Sonam Adventures LLC, (hereinafter “SA”) is neither a medical facility nor a medical provider and therefore has no responsibility regarding medical advice of any type, including inoculations that you or your physician deem necessary for your safe participation.

In the event of a medical emergency, your personal medical information will help us better provide proper medical care and assistance.

Please note that SA respects the confidentiality of your medical information. SA will keep this information confidential and will only use this information to determine whether we require that you consult a physician and provide a confidential medical statement, or, if available, in the event of a medical emergency.
Name: _______________________________
Tour booked: __________________________
Dates of tour: __________________________
Age: ________________                                             Gender: Male                  Female     (circle one)
Completely and truthfully answer all questions:
1. During the last 5 years, have you suffered any significant illness, been diagnosed with a medical condition, been hospitalized or required regular care by a doctor?
Yes            No (circle one)
If YES, please indicate reason: ____________________________________________________
2. Have you ever had any of the followings?
a) Chronic bronchitis, emphysema or any other lung problems?
Yes          No
b) Asthma that effects my everyday activities and/or I use medication or inhaler regularly.
Yes          No
c) High blood pressure, heart or respiratory problems, or rheumatic fever?
Yes          No
d) Heart or respiratory problems, or rheumatic fever?
Yes          No
d) Gout or arthritis or any back, leg or foot problems?
Yes          No
e) Gastric or duodenal ulcer, colitis or intestinal trouble?
Yes          No
f) Epilepsy or seizures of any kind?
Yes          No
g) Depression, anxiety or mental disorder?
Yes          No
h) Kidney or bladder disease?
Yes          No
i) Diabetes, cancer or tumor of any kind?
Yes         No
3. Do you have any physical limitations, disabilities or prosthesis? Do you have difficulty walking or do you use a device for mobility assistance such as a cane or wheelchair?
Yes         No
If YES, please specify: ____________________________________________________________
4. Do you take medication or drugs related to a pre-existing medical condition?     Yes         No

5. Do you have any allergies or reactions to any medication or drugs?     Yes       No
If YES, please specify:
____________________________________________________________
6. Are you pregnant?    Yes        No
If YES, how many weeks pregnant will you be at the time of travel? _____________________
7. Are you affected by any other pre-existing medical conditions not listed above?
Yes            No
If YES, please specify: _____________________________________________________________
Please Note:
* If you indicated “YES” to any of the above questions (excluding question 5), you must consult your physician and provide us with a completed Confidential Medical Statement at least six weeks prior to your departure date.

 

Advance Consent for Medical Treatment


The undersigned hereby authorizes an authorized representative of SA as my agent to give consent to surgical, medical, or dental treatment for me, as well as related transportation, by any licensed physician or provider when such treatment is necessary. Such treatment is necessary when a licensed physician or provider so determines and I cannot reasonably give such consent due to my physical condition. Such consent may include, but is not limited to, administration of necessary anesthetics, medical treatment, X-ray examinations, injections or drugs and the performing of whatever procedures may be deemed necessary or advisable. Further, consent is granted to say physician to exercise his or her discretion in authorizing the disposal of any severed tissue or members.
I understand that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required. This authorization is given to the agent stated herein and to the licensed physician referenced herein to provide the authority to consent to treatment, when in the exercise of his or her best judgment, it is deemed it advisable.
This authorization is effective from ___________ to ________, [insert tour dates], or so long as I am on the trip or tour I booked with SA, or so long as I am reasonably unable to provide such consent and no other lawfully recognized agent, e.g. an immediate relative, has come forward, whichever period is longer and apparently applicable.
____________________________________ ___________________
Signature Date
____________________________________
Print Name