Medical form

Your name*

First Last

Email*

So we can send you a copy of this form...

Which event is this information for?*

This will make sure it is sent to the correct email address

Date of birth*

(dd-mm-yyyy)

Age on event day*

Please enter a number from 18 to 80.

Please give your age at the time of the race event.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current occupation

Please tell us what your current work is.

Please give your height in metres*

If you are not familiar with metric, please Google '5'10" in cm' to get a conversion.

Please give your weight in KG*

If you are not familiar with KG, please Google '150lbs in KG' to get a conversion.

Marital status

Family Physician and/or Primary Health Care Provider

Medical practitioner's name*

Please give the name of your family physician and/or primary health care provider:

physician's address / contact number*

Have you yourself had any formal health related training: ACLS, BLS or other?

This is just so the medic with us is fully informed.

Your experience with mountains and endurance running / hiking*

Can you briefly given an overview of your experience in the mountains and ultra-distance running and/or hiking?

Cigarettes and alcohol

Do you smoke?*

A. Yes
B. No
C. Ex-smoker

How many cigarettes per day?

Please inform us how much you smoke.

In what year did you give up smoking?

How many units of alcohol do you drink in an average week?*

Past Medical History

Please tick Yes or No to all items and explain when Yes

Breathing problems: Asthma*

Yes
No

Breathing problems: COPD (Emphysema / Bronchitis)*

Yes
No

Breathing problems: Recurrent Infections/TB*

Yes
No

Breathing problems: Other*

Yes
No

Breathing problems: Details, dates & medications

You answered yes to one or more of the questions above. Please elaborate here with details, dates & medications

Cardiovascular Conditions: Congenital Heart Disease*

Yes
No

Cardiovascular Conditions: AF or other arrhythmia (even if transient)*

Yes
No

Cardiovascular Conditions: Ischaemic Heart Disease / Angina / MI*

Yes
No

Cardiovascular Conditions: Hyper or Hypotension*

Yes
No

Cardiovascular Conditions: TIA or CVA*

Yes
No

Cardiovascular Conditions: DVT / PE*

Yes
No

Cardiovascular Conditions: Other*

Yes
No

Cardiovascular Conditions: Details, dates & medications

You answered yes to one or more of the questions above. Please elaborate here with details, dates & medications

Endocrine Abnormalities: Hypo or Hyperthyroidism*

Yes
No

Endocrine Abnormalities: Diabetes Mellitus*

Yes
No

Endocrine Abnormalities: Other hormone insufficiency/excess*

Yes
No

Endocrine Abnormalities: Details, dates & medications

You answered yes to one or more of the questions above. Please elaborate here with details, dates & medications

Gastrointestinal Conditions: Inflammatory bowel disease (Crohn’s / UC)*

Yes
No

Gastrointestinal Conditions: Irritable bowel syndrome*

Yes
No

Gastrointestinal Conditions: Malabsorption syndromes / intolerances*

Yes
No

Gastrointestinal Conditions: Details, dates & medications

You answered yes to one or more of the questions above. Please elaborate here with details, dates & medications

Neurological Conditions: Epilepsy / Seizure disorder*

Yes
No

Neurological Conditions: Migraine / Persistent severe headaches*

Yes
No

Neurological Conditions: Recurrent syncope / Other*

Yes
No

Neurological Conditions: Details, dates & medications

You answered yes to one or more of the questions above. Please elaborate here with details, dates & medications

Psychiatric/Psychological Problems: Depression or Mania*

Yes
No

Psychiatric/Psychological Problems: Eating Disorder*

Yes
No

Psychiatric/Psychological Problems: Post Traumatic Stress Disorder*

Yes
No

Psychiatric/Psychological Problems: Any other*

Yes
No

Psychiatric/Psychological Problems: Details, dates & medications

You answered yes to one or more of the questions above. Please elaborate here with details, dates & medications

Eyes, Ears, Nose & Throat: Significant visual disturbance not corrected by glasses or contact lenses*

Yes
No

Eyes, Ears, Nose & Throat: Laser Eye surgery*

Yes
No

Eyes, Ears, Nose & Throat: Significant Hearing problem not corrected with hearing aid*

Yes
No

Eyes, Ears, Nose & Throat: Recurrent Epistaxis or known clotting disorder*

Yes
No

Eyes, Ears, Nose & Throat: Recurrent severe tonsillitis / sinusitis*

Yes
No

Eyes, Ears, Nose & Throat: Recurrent dental problems / major dental work*

Yes
No

Eyes, Ears, Nose & Throat: Details, dates & medications

You answered yes to one or more of the questions above. Please elaborate here with details, dates & medications

Orthopaedic: Osteoarthritis / Inflammatory Joint disease*

Yes
No

Orthopaedic: Fractures to any long bone or with residual problems*

Yes
No

Orthopaedic: Recurrent joint pain (e.g. aching knees etc)*

Yes
No

Orthopaedic: Details, dates & medications

You answered yes to one or more of the questions above. Please elaborate here with details, dates & medications

Surgical: Any operations or significant procedures e.g. appendicectomy*

Yes
No

Surgical: Any HDU/ITU admissions for ANY cause*

Yes
No

Surgical: Hospitalization or frequent doctor visits for any medical /surgical condition not listed here*

Yes
No

Surgical: Details, dates & medications

You answered yes to one or more of the questions above. Please elaborate here with details, dates & medications

Please add any further information about your medical history here…

Have you been diagnosed with any other significant medical/ surgical/ psychiatric condition that is not described above?

Past Altitude History

Have you ever been to altitude >2500m?*

Yes
No

Have you ever taken Diamox before?*

Yes
No

Have you ever had Acute Mountain Sickness (AMS)?*

Yes
No

Have you ever had High Altitude Pulmonary Edema (HAPE)?*

Yes
No

Have you ever had High Altitude Cerebral Edema (HACE)?*

Yes
No

Have you ever been evacuated from a wilderness environment for a medical emergency?*

Yes
No

Any other important altitude related information you would like the course organizers to be aware of?*

Yes
No

Altitude: Further details

You answered yes to one or more of the questions above. Please elaborate here with details, dates & medications etc

Medications

Please list all the medications that you currently take including those you purchase over the counter, those that are/not prescribed by your doctor and those that you take PRN (Ladies please include OCP).

Current medication list*

Medication	Dose	Frequency	Notes

Click button to add a new row

Allergies

Please list ANY allergies (including foods, medications, materials etc), the type and severity of reaction and usual management plan.

Allergen list*

Allergen	Reaction	Treatment	Notes

Click button to add a new row

Immunizations

It is worth consulting the CIWEC Clinic Information website.

Please give information about the Immunizations you've had already that cover Nepal

As a traveller in a managed group, it would be rare to contract a tropical illness, however better safe than sorry. Typhoid and Hepatitis are of particular interest. If you have questions for the medic, please also type them here.

Declaration:

Please tick the box to confirm you've given information correct to the best of your knowledge.

Finally....

This is the end of the form, thank you for taking the time to fill it in. It will be shared with the appointed medic for the event and the Race Director - otherwise it will be kept confidential. You'll be sent a copy now - please take time to check for any errors and let us know if so. Thanks!

Delclaration*

I declare that to the best of my knowledge that the above information I have given is accurate.

Feb 26, 2020 Video: Manuel Ruiz Quilez and The Great Himalaya Trail
	Feb 3, 2020 Pikey Peak gets a full marathon for 2020 – Khiji Demba Marathon 2nd edition
	Jan 13, 2020 Kathmandu has some cleaned up hill trails…
	Dec 21, 2019 1st for Bhim and Sunmaya in Oman
	Dec 6, 2019 KILIAN JORNET AND JUDITH WYDER WIN GOLDEN TRAIL WORLD SERIES TITLES
	Jun 9, 2019 Gosaikund Helambu Trail marathon race review
	Jun 9, 2019 Nepal at the Trail World Championships 2019 in Portugal
	May 25, 2019 Results of the Gosaikunda to Helambu Marathon
	Mar 21, 2019 10 tips for fastpacking in Nepal
	Feb 23, 2019 Bhojpur Trail Race feedback

Medical form

Trail Running Nepal Medical form

Family Physician and/or Primary Health Care Provider

Cigarettes and alcohol

Past Medical History

Past Altitude History

Medications

Allergies

Immunizations

Declaration:

Finally....

Related

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Latest blog posts

Video: Manuel Ruiz Quilez and The Great Himalaya Trail

Pikey Peak gets a full marathon for 2020 – Khiji Demba Marathon 2nd edition

Kathmandu has some cleaned up hill trails…

1st for Bhim and Sunmaya in Oman

KILIAN JORNET AND JUDITH WYDER WIN GOLDEN TRAIL WORLD SERIES TITLES

Gosaikund Helambu Trail marathon race review

Nepal at the Trail World Championships 2019 in Portugal

Results of the Gosaikunda to Helambu Marathon

10 tips for fastpacking in Nepal

Bhojpur Trail Race feedback

Trail Running Nepal Medical form

Family Physician and/or Primary Health Care Provider

Cigarettes and alcohol

Past Medical History

Past Altitude History

Medications

Allergies

Immunizations

Declaration:

Finally....

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Latest blog posts