Please print out, fill in and mail to:
Moon Mountain Adventures, 541 Pioneer Crescent, Parksville
British Columbia, Canada, V9P 1V1

The information that you reveal on this form will be kept confidential. This information is vital. It enables the guide to reduce the risk of injury or illness complications, as well as to prepare contingency plans in the event that an emergency does occur. Withholding details may contribute to injury or illness complications and possibly compromise the care provided in the event of an emergency.

Address 1:________________________
Address 2:________________________
Address 3:________________________
Postal Code:___________ Tel:____-_____

Date of Birth: YY ____ MM ___ DD ___
Male ______ Female ______

Medical Insurance Plan* and ID# :
Doctor:____________ tel ____-_________
In case of emergency, contact:
Home Tel:____-_______ Work:____-_____

General Health:__________Fitness:_________
Physical Limitations:_____________________
Psychological Limitations (i.e. fear of heights, darkness, being alone, etc.) _______________________
Eyesight without corrective lenses:________
Eyesight with corrective lenses:________
with: glasses___ or contacts _____
Dietary restrictions:________________
Medications, Prescription and non-prescription:

Describe allergic reaction:_______________
If allergic to tape or bandaids, please bring hypoallergenic tape.

Medical conditions or illnesses, e.g. high blood pressure, heart condition, seizure disorder, HIV positive, diabetes, hypoglycemia, emphysema, asthma, migraine, etc. ____________

Susceptibility to headaches, nose bleeds, fainting, colds, or sinus problems: No____ Yes ____
if yes, please describe: _________________

Have you been under a doctor's care in the last twelve months? No____ Yes ____
if yes, please describe: __________________

Digestive ailments, do you use antacids, laxatives, etc. on a regular basis: No____ Yes ____
if yes, please describe:__________________

Back problems: No____ Yes ____
if yes, please describe: __________________

Previous history of joint injuries e.g. sprains, dislocations, tendinitis, bursitis, Carpal Tunnel Syndrome etc.: No____ Yes ____
if yes, please describe: __________________

Do you use anti-inflammatory drugs to control joint inflammation? No____ Yes ____
if yes, which types of drugs: __________________

Please continue on Page 2 of Medical Questionnaire

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