First Name

Last Name

Date of Birth (mm/dd/yy)

Email Address

Please answer all the questions as thoroughly as possible, even if it doesn't seem relevant.

Do you suffer from any of the following :

Please explain any items checked above.

Medications

It is very important that we have complete information about any medications before your trip so we can plan appropriately.

Most medications can be managed in the field. Bring extra medication and store in separate places. It may be difficult or impossible to replace prescription meds during the trip.

Are you currently taking any over the counter medications?
Yes No

Will you continue to take these products while on the Expedition?
Yes No

If yes, please describe the condition you are treating, product and dosage:

Are you currently taking any prescription medication?
Yes No

If yes, please describe the condition you are treating, product and dosage:

Allergies

Please advise us of any allergies that you may have. If you have had an anaphylactic reaction to insect bites or stings, it is your responsibility to bring your own adrenaline kit.

Are you allergic to ANY medications?
Yes No

If yes, please list:

Do you have any other allergies (foods, animals, hayfever, anything..)?
Yes No

If yes, please explain:

Are you allergic to bee/wasp stings?
Yes No

If yes, do you carry an adrenaline kit? What type?

Are you receiving "allergy shots"?
Yes No

If yes, please give details.

Are any of your allergies anaphylactic?
Yes No

If yes, please explain:

Diet

Our trips offer an excellent variety of foods, especially considering we must carry it all on our backs. Still, a flexible attitude towards food will help you enjoy the adventure. While vegetarians are usually easily accommodated, other strict dietary restrictions may be difficult or impossible to manage and should be discussed in advance.

Do you follow a special diet?
Yes No

If yes, please explain:

Do you restrict certain foods from your diets for health reasons, religious belief, personal preference, etc?
Yes No

If yes, please explain which foods and reasons:

Do you have concerns about access to certain foods during the trip?
Yes No

If yes, please explain:

How many glasses of water (8 oz) do you drink in a typical day?

How many cups of caffeinated beverages do you drink in a typical day?

Lifestyle

Do you smoke?
Yes No

If you smoke, do you tend to need antibiotics for treatment of respiratory infection?
Yes No

Are you bothered by tobacco smoke?
Yes No

Please describe your participation in outdoor activities; what activity, how often and at what level (beginner, social, competitive, way of life..):

Please describe your current level of fitness:

Emergency Contact Information

Please provide complete details. Include telephone area codes as well as country/city codes if outside the US.

Primary emergency contact:

Name:

Relationship:

Address:

Secondary emergency contact:
Please do not include someone else on this Extremely Patagonia Adventure.

Name:

Relationship:

Address:

Health Insurance Information
You are responsible for the costs of any and all medical care and evacuation. You are reqired to carry medical and evacuation insurance for this reason.

Health Insurance Company:

Policy Number:

Contact Number:

Secondary Contact Number: