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Do You Have What It Takes?

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Adventure Evaluation

This questionnaire is designed to assess your skill and health level. (Required fields are marked with an *)

Name*

This field is mandatory.

Email Address*

To assess your Skill Level at the required activity for your adventure, please rate yourself for each of the activities that apply on a scale of 1-5 with 1 being ‘beginner’, 3 being ‘intermediate’, and 5 being ‘expert’:

Mountaineering*

Road Cycling*

Backpacking*

Kayaking*

Whitewater Rafting*

Skydiving*

Climbing*

Swimming*

Mountain Biking*

Please answer each of the following health questions by providing detailed information that includes dates and medical response. Please let me know of any changes!

Have you ever had frostbite or any other form of cold weather injury?* Yes No

If yes, please provide details.

Have you ever experienced any form of altitude sickness?* Yes No

If yes, please provide detailed information on rate of ascent, altitudes, medications taken, and how the illness was dealt with.

In the past two years, have you had any major accidents or illnesses?* Yes No

If yes, please describe.

Do you have any physical limitations or medical conditions that might restrict your full participation in this program?* Yes No

If yes, please describe.

Specifically, have you ever dislocated a shoulder?* Yes No

If yes, please describe the injury.

Do you have any knee problems?* Yes No

If yes, please describe.

Will you be taking any medications during this trip?*

If yes, please describe.

Do you have any known allergies?

To Food:* Yes No

If yes, please describe.

To Medications:* Yes No

If yes, please describe.

To Bee Stings:* Yes No

If yes, please describe.

Do you have any specific dietary needs (i.e. vegetarian)?* Yes No

If yes, please describe.

Do you wear contact lenses?* Yes No

Are you familiar with standard first-aid and CPR techniques?* Yes No

Please describe.

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