Medical Information

TRAVELER’S MEDICAL INFORMATION

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?

LIST ALL MEDICATIONS THAT YOU ARE TAKING AT THIS TIME, THE DOSAGES AND THE CONDITION THAT IS BEING TREATED:

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?

EMERGENCY CONTACTS

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://www.ibrahimtours.com/