swazi mangala

MEDICAL QUESTIONAIRE SWAZI MANGALA.
PLEASE COMPLETE AND RETURN (1 PER RIDER) TO FAMILY ADVENTURES THE FOLLOWING INFORMATION: THESE
DETAILS ARE VITAL TO CUT DOWN ON TIME IN EVENTUALITY OF ANY EMERGENCY, AS THE MEDICAL CREW WILL HAVE
FORMS WITH THEM.
NAME AND SURNAME ______________________________________________________________
CONTACT NUMBER _________________________________________________________________
EMERGENCY CONTACT PERSON__________________________ NUMBER______________________
ARE YOU CURRENTLY ON A MEDICAL AID : YES / NO
IF YES : MEDICAL AID COMPANY: ________________________________________
o MEDICAL AID NUMBER : ________________________________________
o MEDICAL AID PLAN
o MAIN MEMBER ID NO
: ________________________________________
: ________________________________________
DO YOU HAVE ANY CURRENT MEDICAL CONDITIONS : YES / NO
IF YES PLEASE FURNISH DETAILS:
(EG: CARDIAC/DIABETES/EPILEPSY ETC)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_____________________________________________________
- ARE YOU TAKING ANY CURRENT MEDICATION : YES / NO
- IF YES PLEASE LIST
DETAILS:___________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________
- DO YOU HAVE ANY ALLERGIES : YES / NO
IF YES PLEASE LIST:
-
HAVE YOU HAD ANY MAJOR SURGERY : YES / NO
IF YES PLEASE LIST:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_____________________________________________________