Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Wilderness Medicine Expedition Registration
Participant Name
Date of Birth
____ / ____ / ________
Expedition Destination
Maximum Altitude Planned
Previous Altitude Experience
Altitude Sickness History
Current Fitness Level
Chronic Medical Conditions
Current Medications
| Medication | Dose | How often |
|---|---|---|
Emergency Evacuation Insurance
- Yes
- No
- Not sure
Wilderness Medicine Expedition Registration template from formisoft.com. formisoft.com/intake-templates/wilderness-medicine-expedition-registration