Walkingjersey.co.uk
Medical Registration Form .
Please complete this questionnaire and return it with your
booking form (and Doctor's letter if you are over 60
years of age). It is for your own safety that we find out as much as possible
about your medical history. Your
answers will be treated in the strictest confidence and will not adversely
effect your chances of participating in
any of our tours. Any decisions will be made in consultation with you.
Name: ..................................... Date of
Birth: ................. Age:............
Are you taking any medication? (If so please give details and
dosage below) Yes.....
No....
Have you been hospitalised within the last two years Yes.....
No...
Are you suffering from or are you a carrier of any infectious disease?
Yes..... No...
Are you registered disabled? Yes..... No...
Do you suffer from heart trouble or blood pressure? Yes.....
No...
Asthma, bronchitis and/or shortness of breath? Yes.....
No...
Epilepsy and /or fainting attacks? Yes..... No...
Migraine? Yes..... No...
Severe head injury? Yes..... No...
Psychiatric or mental illness? Yes..... No...
Back problems? Yes..... No...
Allergies? Yes..... No...
Fractures, tendon, ligaments/cartilage damage? Yes.....
No...
If you answered yes to any of the above please give details below:
Next of
Kin:.........................................................................................
Full
name...........................................................................................
Address...................................................................................................................
...............................................................................................................................
Phone...................................................................please
give phone codes (day)
Phone ................................................................. please
give phone codes (eve)
To the best of my knowledge this is an accurate description of my medical
history and current condition:
Signature:
.. Date:
..
If you have any questions or queries
please contact us by any of the following :
Kevin Daly
E-mail - admin@walkingjersey.co.uk Tel / Fax / ansaphone 00441534 852944
1 Green Island House, La Grande Route de la
Cote, St Clements, Jersey C.I. JE2 6SA