EMERGENCY CONTACT First Name Last Name Relationship Day time telephone Evening telephone Mobile Email Address INSURANCE INFORMATION Comprehensive insurance should be purchased before traveling. Travel Insurance should at least cover personal accident, medical expenses, hospitalization, repatriation, trip curtailment, cancellation, and loss of valuables. Insurance Company Insurance Reference Insurance Emergency Telephone Any other relevant information MEDICAL & DIETARY INFORMATION Allergy 1 Alergic reaction 1 Medication required 1 Allergy 2 Allergic reaction 2 Medication required 2 Allergy 3 Allergic reaction 3 Medication required 3 Any other allergies or medication MEDICATION Medication 1 Medication 1 is taken for Medication 1 dosage Medication 1 start date Medication 1 known side effects Medication 2 Medication 2 is taken for Medication 2 dosage Medication 2 start date Medication 2 known side effects Medication 3 Medication 3 is taken for Medication 3 dosage Medication 3 start date Medication 3 known side effects Other medication info MEDICAL HISTORY I have had a seizure within the last 2 years YES NO Hospitalization / Emergency room visit in the past 2 years YES NO History of heart attack, bypass, or rhythm abnormality YES NO Medical device (hearing aid/prosthetic device) YES NO Orthopedic problem, neck, back, ankle or knee YES NO Currently pregnant YES NO Asthma YES NO Diabetic requiring medication YES NO Organs removed YES NO If yes, which one(s) HEART RISK ASSESSMENT YES NO Diagnosed high blood pressure YES NO Smoker YES NO Abnormally high cholesterol level YES NO Family history of heart attack, bypass, sudden unexplained death before 60 YES NO Unexplained chest pain, shortness of breath, heart palpitations, sweats YES NO Fainting spells, dizziness YES NO ACTIVITY LOG Any of our trips involving hiking or other strenuous activity requires that participants be reasonably fit. Please indicate below regularly performed exercise activities. For safari only trips it is not necessary to fill out this section Activity Frequency / time / distance ARRIVAL AND DEPARTURE DETAILS Date of arrival Port / Airport of arrival Airline and number Time of arrival Date of departure Port / Airport of departure Airline and number Time of departure PREFERENCES & SPECIAL INTERESTS Wherever possible we will try to cater for specific preferences or interest, such as bird watching, animal behavior or cultural interests. Please let us know any additional information below. Drinks preferences Other preferences Additional information
