Imagine testing Name of the Expedition/Peak Start Date: Personal Details Full Name Preferred Name: Mailing Address Home Phone Work Phone Cell Occupation Email Address Date of Birth Gender MaleFemaleOther Passport Details Nationality Passport No Date of Issue Place of Issue Date of Expiration Next to Kin Information Full Name Relationship to you Home Phone Cell Email Address Family Information (For climbing in Pakistan Only) S.No. Name Relation Address Nationality Profession Contact No. Email Address + Add Members Medical Information 1. Please state any physical or mental condition, allergy, illness and/or injury that could be relevant. 2. Do you have any dietary requirements? If yes, please list all dietary restrictions. 3. Have you ever had frostbite or any related cold weather injury/illness? If yes, please describe. 4. Have you ever experienced any form of altitude illness? If yes, please describe. 5. Are you on medication? If yes, please list all medications taken during the trip with reasons. 6. Do you wear corrective lenses? If yes, please mention how you manage with ski goggles? 7. Please mention if you have any pre-existing medical conditions not mentioned above. I hereby insist that the information provided is accurate to the best of my facts and beliefs. Signed Date: Please print full name
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