Confidential Health Questionnaire – Nepal Trek and/or Thai Retreat

When ordering your Tropical Thailand Tour & Healing Retreat, or your Rhododendron Trek in Nepal, please fill the following health questionnaire:

NAME: ______________________________________________

ADDRESS: ___________________________________________

PHONE: ______________________________________________

 

1. Do you wear a Medic-Alert Tag? ______________ Specify ________________________
2. Have you ever had a heart attack of any kind? ________________________
3. Have you ever been told by a doctor that you have high blood pressure, a heart murmur, or any other heart disease? ___________________________________________
4. Do you experience anaphylactic shock from bee stings? _______________________
5. Have you ever experienced a seizure of any kind? ____________________________
6. Do you have allergic reactions to any environmental substance, foods, or drugs? ___________ Specify   _______________________________________________
7. Do you have hemophilia? _________________________________________
8. Have you ever had lung cancer? ____________________________________________
9. Do you have any disabilities of back, hips, knees, or ankles? __________________________
   Specify  _____________________________________________________________
10. If you walked on level ground for a mile at an average pace would you get out of breath, have pains in the chest, develop muscle fatigue, or have pains in your legs? ___________________
11. Are you taking any medication prescribed by a physician?   
    Specify______________________________________________________
    ____________________________________________________________
12. Do you have hypoglycemia? ____________________________________________
13.  Are there any reasons why you should not fast? _____________________________
14. If you are under the care of a doctor, would he or she disapprove of your entering this activity?
    _____If “yes,” why? ____________________________________________________
15. Have you ever had psychiatric treatment? ____________________________________
16. Do you have any psychological handicaps that you feel could interfere with this activity? Specify _____________________________________________________________
17. Important: If you have any health concerns you wish Dr. Tel-Oren to address (in a confidential manner) either during this coming trip or at any time after it, please list them here: _______________________________________________________________
    _______________________________________________________________
    _______________________________________________________________
    _______________________________________________________________
    _______________________________________________________________
    _______________________________________________________________

Additional Notes
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
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Signature: ____________________
Address: _______________________________________ Date: ___

 

EMERGENCY USE

CONTACT PERSON: NAME AND PHONE: ____________________________________

DOCTOR’S NAME AND PHONE: ____________________________ _______________

MEDICAL INSURANCE: __________________________________________________