Medical

Personal info

Name

Your email

Date of birth

dd/mm/yy

Address

Sex at birth

Gender identity

Next of Kin

Name and telephone

Doctor/GP info

Name of your Doctor/GP

Your Doctor's/GP's address

Your Doctor's/GP's phone number

Medical info

Do you have any specific access requirements or additional needs?

Yes

Explain

Please list any past or present medical conditions that may be relevant to participation in any aspect of this trip.

Please include a full list of any prescription medications that you currently use and detail the dosage instruction. (how much/ how often)

General Health Questions

Please read the questions below carefully and answer each one honestly:

Check YES or NO.

Has your doctor ever said that you have a heart condition?

Yes

Has your doctor ever said that you have high blood pressure?

Yes

Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

Yes

Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?

Yes

Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

Yes

PLEASE LIST CONDITION(S) HERE

Are you currently taking prescribed medications for a chronic medical condition?

Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?

Yes

Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.

PLEASE LIST CONDITION(S) HERE

Has your doctor ever said that you should only do medically supervised physical activity?

Yes

Further instructions

If you answered NO to all of the questions above, you are cleared for physical activity. If you answered YES to one or more of the questions above, you will need to fill out a more extensive form when you arrive in Stockholm.

Disclaimer

• In the event of accident, emergency or illness on this trip I hereby give permission to MGE to initiate medical treatment and contact my next of kin (as detailed in my application form) as appropriate.

• To the best of my knowledge my mental and physical health and fitness are good and that the information provided is an accurate and up to date description on my past and current medical condition. I agree to take with me sufficient supplies of any medication required for current or previous conditions that may reasonably be expected to occur for the duration of the trip.

• I agree that MGE may approach my GP to verify information on this form to attain further details should it be necessary, and that my GP may release these details.

• I understand the MGE cannot accept responsibility for any liability or expenses resulting from any illness injury or untoward occurrence arising from any undisclosed medical contrition (other than to the extent of death or personal injury arises as a result of negligence).

• I confirm that I will immediately inform MGE of any change to the health information that I have provided.

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