Medical Information

PARTICIPANT MEDICAL INFORMATION FORM
We ask for this information so that our staff will know in advance of special medical conditions you may have, rather than
learning about them in a crisis. Also, in the event of serious injury or illness, this form provides emergency medical personnel
with a useful medical history. After reviewing this form, a RNR guide may contact you to discuss whether the trip will be
safe and enjoyable for you considering your medical history.
We will keep the information on this form confidential. It will be seen only by staff, medical personnel, or others who
know and understand its confidential nature. The form will be retained along with your liability waiver for at least one
year following the trip, after which it will be destroyed. If you choose not to go on the trip, this form may be destroyed immediately.

"Yes" answers to any of the questions on this Form do not automatically exclude a participant from a RNR activity.
However, the RNR, at its sole discretion, may not allow in dividuals to participate in any activities that could have a reasonable
likelihood of causing harm to the participant or others due to a medical, physical or psychological condition.
Failure to report current and pertinent medical information could result in injury or illness or compound an existing injury or
illness to any participants involved in a RNR activity.

Name:*
Address:*
E-mail:*
Phone:*
-
Gender*
Day of Birth*
Weight (250lb limit weight)*
Height*
If you carry medical insurance, please provide the name of your provider and policy or member number.
Emergency Contact*
Emergency Phone:*
-

GENERAL MEDICAL HISTORY

Please complete all parts of this medical information form and return it to the Rock n Rope Adventures (RNR) Service before the date of your scheduled activity. The RNR uses this information to help us understand your needs and accommodate you during your climbing experience. Please circle "YES" or "NO" for each item. Each question must be answered. Please provide specific information regarding each condition, illness or injury including dates if appropriate for all "YES" answers.

Do you have a history of respiratory problems or asthma?*
Is the asthma well-controlled by an inhaler or other medication?
If you have asthma, when was your last attack?
Briefly describe what triggers an attack? - Note: If you use an Inhaler, please bring one with you.
Do you have a history of problems with balance, dizziness, loss of consciousness or seizures?*
If yes, please explain:
Do you see a physician on a regular basis for any medical condition?*
If yes, please describe the issue and provide contact information for the physician.
Have you been hospitalized in the past five years?*
If yes, for what condition?
Do you currently have or do you have a history of any muscular-skeletal injuries (e.g. muscle/tendon injuries, joint injuries, including sprains or back injuries)?(1)*
Do any of these current or past injuries limit your capacity for physical activity?joint injuries, including sprains or back injuries)?(1)*
Do you currently have or do you have a history of any known allergies, including: foods, medications and insect bites or stings?*
If so, what causes the allergic reaction?
Note: If you have been prescribed an epinephrine injector for anallergic condition, please bring it with you.
RNR does NOT stock epinephrine in its First Aid Kits.

MEDICATIONS

Note: If you will need to take a prescription medication during your RNR activity, please bring it with you.

Are you taking any prescription or non-prescription medications?*
Please provide the following information for any medications you are taking: Medication: Dose/Frequency: Known Side Effects/Interactions: Restrictions: For what condition?
Do you have a history of any medical condition, disease or disorder not described above?*
If yes, please explain.
Do you have any conditions that would limit your participation in rock climbing activities?*
If yes, please explain.(1)
Activity *
Activity Date:
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