Medical Form

The information you provide to VOPO in this form will be held in the strictest confidence, and will be used only to the extent necessary to provide necessary emergency medical care and/or evaluate fitness for travel.

Who should complete this form?

All Expedition and Inhabit Project participants must complete sections ‘A’, “B”, and “C”’. If you have indicated that you have a pre-existing medical condition you are required to complete section ‘D’ also. The more information VOPO has, the more we may assist in the unlikely event of an emergency or provide other medical assistance. Please note VOPO will assess the information contained in this form, and reserve the right to ask for a physician assessment for any participants.

Why do I need to complete this form?

Our expeditions take you to remote areas where limited or no sophisticated medical facilities exist. A medical emergency situation is unlikely; however, should it arise we are armed with the necessary information to help you. You must provide complete, accurate, and up-to-date information on this form in order to allow VOPO Expeditions to safely accommodate you. 

If there are any changes to your physical/medical condition or otherwise to your responses below after your submission of the form to VOPO, you must notify VOPO immediately of that change. 

How do I complete this form?

It is very important for your own health and safety that you complete all questions fully and truthfully. In the event of a medical emergency, the information you have provided could be crucial. All participants must complete, and return sections ‘A’, ‘B’, ‘C’ If participants answer yes to any question in section ‘B’, then proceed to section ‘D’. Part 1 of section ‘D’ must be completed by yourself, and Part 2 given to your medical practitioner to complete on your behalf. 

Section A - General Information
Type, Location, Date
Name *
Name
Section B - Medical Information
1. During the last 5 years, have you suffered any significant illness, been hospitalized or required regular care by a doctor?  *
2. Have you ever had any of the following:
a) Tuberculosis, chronic bronchitis, emphysema or any other lung problems? *
b) Asthma effects my everyday activities and/or I use medication or an inhaler regularly *
c) High blood pressure, heart or respiratory problems, or rheumatic fever? *
d) Gout or arthritis or any back, leg or foot problems? *
e) Gastric or duodenal ulcer, colitis or intestinal trouble? *
f) Epilepsy or fits of any kind? *
g) Kidney or bladder disease? *
h) Diabetes, cancer or tumour of any kind? *
3. Do you have any physical limitations, handicaps or prosthesis? Do you have difficulty walking or use a device for mobility assistance such as crutches, cane or wheelchair? *
4. Do you take medication or drugs related to a pre-existing medical condition? *
5. Do you have any allergies, or reactions to any medication or drugs? *
6. Are you pregnant? *
7. Are you affected by any other pre-existing medical conditions not listed above? *
Section C - Details
Date of Birth *
Date of Birth
No sophisticated medical facilities may not be available on our other itinerary or locations to which VOPO travels. Although our Expedition Leaders will carry a limited first aid kit and equipment, we ask you to complete this confidential medical report so that all due care may be provided. Expedition travel is intended for persons in reasonably good health and with full mobility. Participants who are not fit for this expeditions for any reason, including mobility issues, disability, heart or other health condition are advised not to join the tour, which would entail an unreasonable risk to your health and to the enjoyment of all those aboard. I attest I am in good general health, and capable of performing normal activities on this expedition. I further attest that I am capable of caring for myself during the expedition, and that I will not impede the progress of the expedition or the enjoyment of others aboard. I understand that this expedition will take me far from the nearest medical facility and that all expedition members must be self- sufficient. With that understanding, I certify that I have not been recently treated for, nor am I aware of, any physical or other condition or disability that would create a hazard to myself or other members of the expedition. I agree that should there be any change to the information I have given herein or to my physical or medical condition that I will notify VOPO and, if requested, provide an up- to-date version of this completed form. I agree that any failure to provide full and complete medical information to VOPO may result in the cancellation of my booking without further compensation payable to me for any loss.
I declare the answers to the above questions are true and complete. I agree to this information being made available to VOPO.
Date
Date