MEDICAL FORM

Please sign and return your completed medical form, together with the questionnaire form to:

Norwood Challenges, Broadway House, 80-82 The Broadway, Stanmore, Middlesex, HA7 4HB

Tel: 020 8420 6834 Fax: 020 8420 6800 Email:

This form should be completed by all applicants. All information supplied in this form will be treated as strictly confidential.

PERSONAL DETAILS

First Name:……………………………..….. Surname: ………………..……………….………………

MEDICAL DETAILS

The event in which you will be participating is challenging and will require a good level of fitness, strength and endurance. It is your responsibility to ensure that you have the appropriate level of fitness. The event is not recommended for those with any infirmity. You should check with your doctor to ensure that you are sufficiently fit and healthy to participate. You should take into account that medical and other facilities at the destination may be inferior to those in the UK.

  1. Heart diseaseYes/No
  2. Raised blood pressureYes/No
  3. Respiratory diseaseYes/No
  4. Hay feverYes/No
  5. Epilepsy or seizuresYes/No
  6. Diabetes (please state type 1 or 2)Yes/No
  7. Joint/fracture/tendon/ligament/cartilage damageYes/No
  8. Back injuryYes/No
  9. Heat or cold related illness such as heat strokeYes/No
  1. Vertigo or fear of heightsYes/No
  2. Altitude sicknessYes/No
  3. Sight, hearing or other sensory impairmentYes/No
  4. Digestive or bowel disordersYes/No
  5. Cerebral disease (stroke/ head injury/tumour)Yes/No
  6. Haematological or blooddisordersYes/No
  7. Thyroid or hormonal problemsYes/No
  8. Circulation problemsYes/No
  9. Any other conditionYes/No

  1. Blood clots/ deep vein thrombosis/pulmonary embolism Yes/No

  1. Psychological or psychiatric illness including eating disorders/ deliberate self-harm/ overdoses/depression/

Anxiety/stress/psychosis/alcoholism or drug dependency Yes/No

  1. Do you have any objections to treatment, including blood transfusionsand immunisations Yes/No

ASTHMA Yes/No

please answer the following:

When was the last time you needed hospital treatment?......

When was the last time you needed steroid tablets?......

What medication/inhalers do you currently use?......

ALLERGIES Yes/No

Are you allergic to Nuts/Penicillin/Wasp/ Bee Stings/Other……………………………………………………………

Have you undergone hospital treatment in the last 12 months Yes/No

Blood Group (if rare): ..……..………Height …….…………..…Weight ………………..BMI …………………..

Please list any medication you are currently taking and ensure you bring enough supplies for the length of the trip

………………………………………………………………………………………..……..……………..……………..………..………

……………………………………………………………………………………………………….…………………….………………

If you have ticked ‘Yes’ to any of the above, have undergone hospital treatment or have any other condition not listed above, please give details

……….……………………………………………………………………………………………………….………………..

……………………………………………………………………………………………………………….…………………

DOCTOR’S DETAILS

The trip doctor may wish to speak to your GP prior to your place being confirmed. Please provide your GP’s contact details below:

Doctor’s Name: / Surgery Telephone:
Surgery Address:
Email:

We reserve the right to ask you to provide a copy of the summary sheet from your GP records at your own expense (there is a standard NHS charge for this) if the trip doctor of our medical advisor considers it necessary.

NEXT OF KIN

First Name: / Surname:
Address: / Postcode:
Relationship: / Email:
Daytime Tel: / Mobile Tel:

PARTICIPANT’S SIGNATURE

If Norwood reasonably considers that your safety or that of other participants may be compromised by your participation we reserve the right to refuse your participation on medical grounds. Any decision will be made in consultation with you and your GP.

I confirm the following:

1) I understand this challenge is physically challenging

2) I have understood the need for fitness and will read the training guidelines and commit to a training programme for the event.

3) This is a true and accurate description of my medical history and current condition.

4) I give my consent to Norwood to release this information to the medical personnel accompanying the event to allow him/her to contact my GP for further details.

5) In the event of illness or an accident on the trip I hereby give my permission for medical staff to initiate and deliver medical treatment, and notify my next of kin in case of hospitalisation.

6) I am responsible for organising my own vaccinations through my GP and will be expected to bring a personal first aid kit and any medication that I need.

7) If I have selected the Norwood Group Insurance Policy, I agree to notify Norwood of any changes in my medical condition. I understand that failure to do this may invalidate my insurance

8) If I have am using my own insurance company, I will advise my insurer of any medical conditions. Should I fail to do this, I understand that I will be liable for any medical costs incurred as a result of my condition

Signed…………………………………… Name (Capital Letters) …..…………………….Date …………………

IMPORTANT! Should any of your medical details change after you have submitted this form,

please inform Norwood immediately. You will be asked to complete a new medical form.

It is vital that you remember to do this for your own safety.

DOCTOR’S DECLARATION

If you are aged 65 years or over, are taking part in a high altitude challenge (2,500 metres or higher) or you have any of the medical conditions listed, you must ask your doctor to sign below. Before you are accepted on the challenge, your application may be assessed by the trip doctor for further consideration prior to your place being accepted.

When you visit your doctor to discuss the challenge, please take a copy of the itinerary with you (which is available on our website).

EVENT DETAILS

Date and Destination ……………………………………………………………………………………………………..

Type of Activity (Trek or Bike Ride) ………………………………….No of activity days ………………….

Distance (Bike Ride) ………………. Hours per day (Trek) …………………. Altitude (if over 2,500m) …………

PERSONAL DETAILS

Title (Mr/Mrs/Ms/Other) …………………………....Surname ………………………………….…………...….

Forenames ……………………………………………Nationality …………………………………..……………..

Address ……………………………………………………………………………………………………………….……..

………………………………………………………………………………………………………………………….…….

……………………………………………………….Postcode ………………………………………………......

Date of Birth ……………………………………………Age………………………………………………………….

Height (m) …………Weight (kg…………BMI ………………Blood Group (f rare) …………………..

DOCTOR’S SIGNATURE
I confirm that I have read the itinerary my patient is planning to undertake and I know of no reason why this person should not participate in an event of this type at this point in time.
Doctor’s Name …………………………………… GP Practice Stamp
Doctor’s Signature ……………………………….
GMC Number …………………………………….
Date ……………………………………………….

Please return your signed form to:

Norwood Challenges, Broadway House, 80 – 82 The Broadway, Stanmore HA7 4HB

Email: or fax: 020 8420 6800