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Bath University Mountaineering Club Health Form

This form is CONFIDENTIAL. You are not required to tell us, but please be aware that
anything you write on this form will be kept in confidence. The original copy will be kept
securely by the Secretary. For trips, a photocopy will be sent out in a sealed brown envelope
in the first aid kit and only opened in the event of an emergency.
First name:
Surname:
Date of birth:
Age:
Gender:
Any pre-existing
medical conditions (if
so please provide
details):

Allergies (to food,


medication etc. If yes,
please provide details)

Listed below are conditions that a medical professional would like to have details on if an
event on the hill were to occur. Please circle Yes or No depending on your circumstance.
Do you have a history of blackouts or fainting?
Do you have a history of migraines?
Do you have diabetes?
Do you have a history of middle ear infections?
Have you had appendicitis?

Yes / No
Yes / No
Yes / No
Yes / No
Yes / No

Next of Kin:
Name of emergency contact:
Emergency contact number:
Relationship to you:
Please print name here:
Please sign here:

Date: