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Personal Information
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How Did You Learn About MCC?
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Participant Medical History
Climbing and skiing in general and at high altitude is extremely strenuous. In addition, medical care may not be immediately available in the backcountry. We do not want you to engage in any activity that would be detrimental to your health or which would be opposed by your doctor because of recent illness, injury, surgery, etc. If you have any questions regarding your participation in the trip or expedition, please contact your doctor.
Please list any major accidents, illnesses or operations you have had in the past five years
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Any History Of :
asthma
hernia
migraines
cancer
diabetes
frostbite
head injury
hypoglycemia
circulation issues
bleeding disorder
heart condition
seizure disorder
intestinal problems
hearing impairment
respiratory condition
kidney problems
chronic infection
blood disease
vision impairment
altitude sickness
currently pregnant
back or neck problems
ankle or knee problems
arm or shoulder problems
high or low blood pressure
irregular heartbeat or murmur
joint dislocations or severe sprains
intolerance to cold or warm temperatures
other (please explain below)
If you marked any of the above, please explain below or attach a separate sheet if more room is needed. Please include date, length, severity, treatment, current symptoms and limitations:
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List any/all physical limitations or medical conditions that may restrict your ability to participate in this program. Attach a separate page if needed.
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List any/all medications that you take regularly or intermittently and why:
By checking the box below, I verify that the information I have provided on MCC Participant Medical History is true, complete and correct.
1
Fitness and Experience Level
How would you rate your current level of physical fitness:
Excellent
Above Average
Average
Below Average
Poor
In regard to the specific trip you are participating in, please give a detailed account of your experience and level. Be specific to the individual sports, ie: rock and ice climbing, alpine ascents, and skiing:
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Please describe your average weekly workouts
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