Don Duncan's

Alaska Private Guide Service

299 Alvin Street

Fairbanks, AK 99712

907-457-8318

 

MEDICAL AND PHYSICAL CONDITION INFORMATION FORM

NAME: _______________________________________________________________________________________

ADDRESS: ____________________________________________________________________________________

CITY: ________________________________________________ STATE: ___________ ZIP: _________________

TELEPHONE: ________________________________ OCCUPATION: ___________________________________

AGE: ____________________ HEIGHT: ____________________________ WEIGHT: ______________________

HUNTING EXPERIENCE: _______________________________________________________________________

 

I, _________________________________________, (CLIENT) AS LAWFUL CONSIDERATION FOR CONTRACTING ALASKA PRIVATE GUIDE SERVICE FURNISH THE FOLLOWING MEDICAL, HEALTH AND DIETARY INFORMATION TO OUTFITTER WHICH I STATE TO BE TRUE AND CORRECT, AND ACCEPTING RESPONSIBILITY FOR FAILURE TO DISCLOSE ANY CONDITION OR NOT FULLY STATING SUCH CONDITION. I UNDERSTAND THAT I MUST FURNISH COMPLETE INFORMATION TO INCLUDE PHYSICIAN’S REPORTS IF THE CONDITIONS WOULD OTHERWISE BE CONSIDERED TO BE DETRIMENTAL TO MY HEALTH IF NOT DISCLOSED. I WILL ATTACH OTHER SHEETS IF NECESSARY TO FULLY DISCLOSE MY CONDITION(S).

 

HAVE YOU EVER HAD OR BEEN DIAGNOSED AS HAVING HEART OR CORONARY ARTERY DISEASE? ______ YES _________ NO. IF YES, DESCRIBE ANY LIMITATIONS ON ACTIVITIES, MEDICATIONS OR OTHER RELEVANT INFORMATION: _________________________________________________________________________________________

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DO SUFFER FROM HIGH BLOOD PRESSURE? ________ YES _______ NO. IF YES, DESCRIBE ANY LIMITATIONS ON ACTIVITIES, MEDICATIONS OR OTHER RELAVANT INFORMATION: _________________________________________

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HAVE YOU EVER BEEN EXPOSED TO HIGH ALTITUDE: _________YES ________ NO. HAVE YOU EVER HAD ALTITUDE SICKNESS: _________ YES _________ NO IF YES PLEASE DESCRIBE THE SYMPTOMS: ________________

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ALLERGIES (INCLUDING ALLERGIC REACTIONS TO SPECIFIC MEDICATIONS) OR OTHER PHYSICAL CONDITIONS THAT REQUIRE SPECIAL ATTENTION OR MEDICATION: _________ YES _________ NO. IF YES, DESCRIBE CONDITION AND/OR MEDICATION: ____________________________________________________________

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DIETARY RESTRICTIONS: _________________________________________________________________________________

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DO YOU SUFFER FROM ANY CONTAGIOUS BLOOD, KIDNEY OR INTESTINAL DISEASES OR INFECTIONS? ____________ YES ____________NO. IF YES, PLEASE EXPLAIN: _____________________________________________

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ANY OTHER CONDITION THAT REQUIRES TAKING OF DAILY MEDICATIONS OR CARRYING OF SPECIAL MEDICATION OR EQUIPMENT? _________ YES ________ NO IF YES, DESCRIBE THE CONDITION, MEDICATION, OR EQUIPMENT REQUIRED, ANY RESTRICTIONS CAUSED BY THE SAME AND ANY SPECIAL INSTRUCTIONS NEEDED BY THE OUTFITTER: ____________________________________________________________________________

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I understand that prescriptions will be hard if not impossible to fill; so I will bring all my own personal prescribed medication in sufficient quantities for my stay including weather delays.

 

 

SIGNATURE _____________________________________________________________ DATE ________________________