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

continued from Page 1

Date of Birth: YY ____ MM ___ DD ___

Previous history of cold injury, e.g. frostbite, trenchfoot etc.:
No____ Yes ____
if yes, please describe: __________________

Previous history of heat injury, e.g. hyperthermia, heat or sunstroke etc.: No____ Yes ____
if yes, please describe: __________________

Previous history of altitude illness:
No____ Yes ____
if yes, please describe: __________________

Date* of last tetanus shot or booster:
YY____ MM _____ DD ______
*Current (within 10 years) is required for any trip 3 days or longer

I, ________________________________
please print your name

have honestly disclosed all of the information requested in the above questions; and, I understand that withholding information may contribute to injury or illness complications and possibly compromise the care provided in the event of an emergency. If any of the above information changes prior to or during the trip, I will immediately notify Tom Carter of Moon Mountain Adventures.



If the participant is under 19 years of age, a parent or guardian must sign:

Print name of parent or guardian: ___________________

Signature of parent or guardian: _____________________

Back to Page 1 of Medical Questionnaire
Back to the Information & Questionnaire Index Page
Back to the Moon Mountain Adventures Homepage