020 8150 7155
FULL NAME (AS PER PASSPORT ):
DATE OF BIRTH (DD/MM/YYYY):
BLOOD TYPE (IF KNOWN):
HEIGHT & WEIGHT (IF KNOWN):
EVALUATE YOUR GENERAL HEALTH (PLEASE CHECK THE APPROPRIATE BOX):POORFAIRGOODEXCELLENT
EVALUATE YOUR PHYSICAL CONDITION/STAMINA (PLEASE CHECK THE APPROPRIATE BOX):POORFAIRGOODEXCELLENT
HAVE YOU TAKEN OUT MEDICAL INSURANCE FOR THIS TOUR (PLEASE CHECK THE APPROPRIATE BOX)?YESNO
DO YOU REQUIRE ANY TYPE OF TREATMENT ON A REGULAR BASIS (PLEASE CHECK THE APPROPRIATE BOX)?YESNO
IF YOUR ANSWER IS YES, PLEASE DESCRIBE THE CONDITION:
Do you have, or have you had in the past 5 years, any of the conditions listed below? Please check the appropriate box.
High blood pressureYESNO
Cardiac/heart disease, Coronary acute syndrome, Cardiac tamponade or any otherYESNO
Heart surgeryYESNO
Pulmonary conditions: Asthma/bronchitis, COPD-chronic obstructive pulmonary disease, pulmonary thrombosisYESNO
Blood disorder: haemorrhage (excessive bleeding), clots, anaemia or any otherYESNO
Diabetes: Type 1 or Type 2YESNO
Digestive disorder: stomach ache, stomach ulcers, heartburn, bleeding, constipation, diarrhoea, or any otherYESNO
Skin problem: sores, blisters, skin rash, burns, eruptions, itchiness or any otherYESNO
Allergies: dust, latex or any otherYESNO
Infectious/ contagious diseasesYESNO
Severe headaches - migrainesYESNO
Ear/nose/throat problems: hearing loss, earache, sinusitis, nosebleeds, or any otherYESNO
Restricted mobility/difficulty walking, use crutches, a walking stick or wheelchairYESNO
AmputationYESNO
Do you have a prosthesis or joint replacement?YESNO
Fractures/dislocationsYESNO
StrokeYESNO
Eye/vision problems: pain, dryness, redness, glaucoma, blurred vision, double vision or any otherYESNO
Autoimmune disorders: Lupus, Psoriasis, Celiac Disease(sprue) or any otherYESNO
Are you currently pregnant?YESNO
Thyroid problems such as hypothyroidism /hyperthyroidism or any otherYESNO
Psychiatric disorders such as depression, anxiety or any otherYESNO
Tumours benign/malign: breast, lungs, intestine or any otherYESNO
Urinary system: pain, infections, prostatic hyperplasia (in men), kidney stones, renal failure or any otherYESNO
Spinal column and back problems: muscle contracture, herniated disk, sciatic nerve compression, spinal stenosis, scoliosis or any otherYESNO
Neurological disorders such as loss of consciousness, loss of memory/ balance problems (Alzheimer/Parkinson), epilepsy/seizures, dizziness/fainting or any otherYESNO
Musculoskeletal system: pain in joints, muscle pain, weakness, osteopenia/osteoporosis, swollen ankles/knees or any otherYESNO
IF YOU ANSWERED YES TO ANY OF THE ABOVE, PLEASE DESCRIBE BELOW:
DO YOU HAVE ANY OTHER MEDICAL CONDITIONS NOT MENTIONED ABOVE? PLEASE DESCRIBE BELOW:
DO YOU HAVE ANY MEDICAL ILLNESSES, DISABILITIES OR INFIRMITIES THAT REQUIRE THE REGULAR CARE OF A DOCTOR?
MEDICATION
DOSAGE
WHAT ARE YOU TAKING THIS MEDICATION FOR?
HAVE YOU BEEN HOSPITALIZED OR HAD SURGERY IN THE LAST FIVE YEARS? IF YES, WHEN AND WHAT KIND OF SURGERY?
DO YOU HAVE ANY DIETARY RESTRICTIONS OR FOOD ALLERGIES? IF YES, WHAT ARE THEY? ( WE ARE NOT RESPONSIBLE FOR THE FOOD WHILE YOU ARE TRAVELING WITH US DURING OUR TOURS, PLEASE MAKE SURE WITH THE RESTURANTS )
DO YOU HAVE ANY OTHER PHYSICAL OR MENTAL LIMITATIONS, OR HANDICAPS NOT MENTIONED ABOVE?
NAME
RELATIONSHIP
PHONE NUMBER
DOCTOR’S NAME (BLOCK LETTERS)
NHS NUMBER:
TELEPHONE:
E-MAIL:
ADDRESS:
Tel: 020 8187 1274 Email: admin@ibrahimtours.com Website: https://ibrahimtours.com/
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