Able trek tours

Able Trek TOURS
P.O. Box 384, Reedsburg, WI 53959
Able Trek
1-800-205-6713 FAX - (608)524-8302
MEDICAL EVALUATION
Must be completed by a Medical Physician
TRAVELER’S NAME: __________________________________ Date of exam: _______________
Address: ____________________________________________ City: _______________________ State: ______ Zip: _______ Phone: (_______)_____________________________________ Medical Diagnosis: _______________________________________________________________________ Height __________ Weight _________ BP __________ T ________ P _________ R _________ Is the fol owing normal? If no, explain: 1. Ears _____________________________________ 1. Asthma ________________________________________ 2. Nose _____________________________________ 2. Hernia _________________________________________ 3. Throat ___________________________________ 3. Enuresis ________________________________________ 4. Skin _____________________________________ 4. Recent Fevers __________________________________ 5. Eyes _____________________________________ 5. Recent Weight Loss ____________________________ 6. Scalp ____________________________________ 6. Kidney Disease _________________________________ 7. Heart ____________________________________ 7. Diabetes ______________________________________ 8. Lungs ____________________________________ 8. Stomach Disorders _____________________________ 9. Extremities ______________________________ 9. Frequent Colds/Hay Fever ______________________ 10. Glands __________________________________ 10. Hepatitis ______________________________________ 11. Abdomen _________________________________ 11. Heart Disease _________________________________ 12. Varicosities ____________________________ 12. Previous surgery _______________________________ 13. Genitalia _______________________________ 13. Neurologic ___________________________________ 14. TB or Contact (last test results) ___________________________________________________________________________ 15. Other – explain _________________________________________________________________________________________ Does this person have seizures or convulsions? ________ If yes, frequency _____________________________________ Type ____________________________________________ Last seizure ______________________________________ Any Blood/Body Fluid precaution? If yes, type: ______________________________________________________________ Wil this person require medication while on an Able Trek Tours trip? ____ Yes ____ No If yes, complete below: Name of Medication May this person be given if the need arises? Does this person have any physical disabilities? ____ Yes ____________________________________________________________________________________________________________ Does this person use any special equipment (wheelchair, walker, hearing aid, dentures, etc.) __________________ ____________________________________________________________________________________________________________ Has this person been immunizes against the fol owing and when? Tetanus _____ Yes (date) ________
If not immunized for tetanus in the past 10 years, please do so prior to the scheduled trip.
RESRTICTIONS: Please explain
Diet: _______________________________________________________________________________________________________
Swimming: _________________________________________________________________________________________________
Strenuous Exercise: _________________________________________________________________________________________
Hiking/walking long distances: ______________________________________________________________________________
Other restrictions: __________________________________________________________________________________________
ANY FURTHER RECOMMENDATIONS: _________________________________________________________________________
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Signature of Medical Physician: _____________________________________________________ Date _________________
Please print name: _______________________________________ of exam: ___________ Phone: (____)_____________
This form must be returned to Able Trek Tours at least 21 days before the trip departure date. The evaluation must be completed by a
medical physician within 12 months of the trip departure date. If either of the above requirements is not met, the Traveler becomes
ineligible for Able Trek Tours trips. These requirements help insure proper health care is given by our staff. Traveler’s medications MUST be individual y pre-packaged according to the time and date of each dispensing. DO NOT pack medications in suitcases. Al medications, unless the Traveler self-medicates, wil be given to the Tour Director or person responsible for dispensing them at the time of check-in.
Mail/fax all medical forms at least 21 days prior to the trip departure date to:

Able Trek TOURS
P.O. Box 384, Reedsburg, WI 53959
(608) 524-3021 1-800-205-6713
(608)524-8302 - FAX

Source: http://abletrektours.com/wp-content/uploads/2014/01/2014-MEDICAL-EVALUATION-PHYSICAL.pdf