Medical form

Trail Running Nepal Medical form

Thanks for filling this form out. It is long, but by handling it by email it makes it much easier for everyone, mainly the race medic who can quickly ensure he or she knows your medical history and is fully prepared for the event. NOTE: if you cannot complete the form now, use the “save and continue later” link at the bottom of the 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 dash MM dash YYYY

(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.

Save and Continue Later

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….

Race dates

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