<p> MEDICAL QUESTIONNAIRE</p><p>Please complete all sections electronically, print, sign and post to 11 St Lawrence Road, Canterbury, Kent, CT1 3EY</p><p>This form is taken on each trip and it is essential that the information supplied is correct</p><p>PERSONAL DETAILS</p><p>Participants name Date of birth </p><p>Next of kin name Relationship to you Contact number (Please provide two Next of kin address numbers i.e. home / work / mobile) Second contact Contact number person</p><p>MEDICAL INFORMATION (Please use drop down boxes)</p><p>Are you allergic to any of the following? Do you suffer from any of the following?</p><p>Penicillin No Asthma No</p><p>Nuts No Eczema No</p><p>Bites and stings No Persistent headaches No</p><p>Food allergies No Hay fever No</p><p>Other No Other No If you have said yes to any of the above please give further details:</p><p>Please give details of any medication (prescribed or otherwise) you take regularly:</p><p>Details of your medical history (significant points only please):</p><p>Dietary requirement – please complete if you are vegetarian, vegan or unable (for medical reasons) to eat certain foods:</p><p>Name, address & telephone Blood group number of your GP (if you know it)</p><p> www.canterburygold.org.uk © Copyright Canterbury Gold 2007-2011 Page 1 of 2 IMMUNISATIONS</p><p>By the time you leave for your Qualifying Expedition will you be immunised against any of the following? The list below does not indicate that you require these immunisations – you must discuss with your doctor/practice nurse. (Please use drop down boxes)</p><p>Diphtheria No Meningitis No</p><p>Polio No Rabies No</p><p>Tetanus No TB (BCG) No</p><p>Hepatitis A No Typhoid No</p><p>Hepatitis B No Yellow fever No If you are travelling to Africa you may be advised to take Other Immunisations anti-malaria precautions. If so which malaria tablets are you going to take?</p><p>SIGNATURES</p><p>Signature (Participant) Counter Signature (Parent / This MUST be signed even if Date Guardian if under 18years) under 18years I confirm that the information given in this Medical Questionnaire is correct to date and I will inform Canterbury Gold of any changes should they arise before participation in any activities with Canterbury Gold.</p><p>Should the necessity arise, I agree to the person in charge of the party giving consent on my behalf for an anaesthetic to be administered or for any other urgent medical treatment to be given.</p><p> www.canterburygold.org.uk © Copyright Canterbury Gold 2007-2011 Page 2 of 2</p>