AMAZON ANDES SKY TOUR

MEDICAL QUESTIONNARE

ATTACHMENT B

 

Please review the following questions.

 

 

1. During the last 5 years, have you suffered any significant illness, been hospitalized or required regular care by a doctor?    

 

2. Have you ever had any of the following:

a. Tuberculosis, chronic bronchitis, emphysema or any other lung problems?

b. Asthma effects my everyday activities and/or I use medication or an inhaler regularly?

c. High blood pressure, heart or respiratory problems, or rheumatic fever?

d. Epilepsy or fits of any kind?

e. Diabetes, cancer or tumour of any kind?

f. Gout or arthritis or any back, leg or foot problems?

g. Medically diagnosed depression, anxiety or mental disorder?

h. Kidney or bladder disease?

i. Gastric or duodenal ulcer, colitis or intestinal trouble?

 

3. Do you have any physical limitations, handicaps or prosthesis?

 

4. Do you have difficulty walking or use a device for mobility assistance such as crutches, cane or

wheelchair?

 

5. Do you take medication or drugs related to a pre-existing medical condition?

 

6. Do you have any allergies, or reactions to any medication or drugs?

 

7. Are you pregnant?

 

8. Are you affected by any other pre-existing medical conditions not listed above?

 

9. Do you have any other medical condition which might be aggravated by high altitude?