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/
