Opwall Participant Personal Details And Medical Form
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2Wallace House, Old Bolingbroke,
Spilsby, Lincolnshire, PE23 4EX
Tel: +44 (0)1790 763194
Fax: +44 (0)1790 763825
E-mail:
Website:
2016 OPWALL PARTICIPANT PERSONAL DETAILS AND MEDICAL FORM
Personal Details
Name
(as it appears in your passport)
Date of Birth
Name of School
Home Postal Address
Mobile Number
Sex (M/F)
Nationality
Passport number
(note you will need 6 months remaining on
your passport from your proposed return date)
Passport expiry date
Additional Insurance Provider & Policy No
Emergency contact name at home for when
you are in the field
Relationship of emergency contact to you
Mobile number of emergency contact
Email address of emergency contact
Medical History
Current Medications
If you are taking any medications please list those, including
dosage information and the condition it is used to treat.
Please also include any medications you carry but do not
regularly take, for example epi-pens or inhalers.
If the answer is “non applicable”, please state “NONE” - don’t just leave the section blank.
Allergies
If you have any drug or environmental allergies, please
indicate their nature.
If the answer is “non applicable”, please state “NONE” - don’t just leave the section blank.
Allergies - Severity
If you’ve listed allergies above please describe the severity of
the reaction, and whether you carry an epi-pen in the case of
severe allergies, when your last reaction was, and the
regularity of the reaction.
If the answer is “non applicable”, please state “NONE” - don’t just leave the section blank.
Asthma
Do you currently or have you previously suffered from
asthma? If so please indicate the severity of your asthma and
any known triggers (e.g. exercise). Please note this may
impact marine activities if you are on a project where you
intend to dive. Please see the PADI Medical Statement
documentation for more detail.
If the answer is “non applicable”, please state “NONE” - don’t just leave the section blank.
Current Health Issues
Please list anything you regularly see a doctor for, is
reoccurring, requires ongoing treatment, or any physical
impairments
If the answer is “non applicable”, please state “NONE” - don’t just leave the section blank.
Current Psychiatric or Behavioural Issues
Please include include any effect these have on your daily life
and any triggers where applicable.
If the answer is “non applicable”, please state “NONE” - don’t just leave the section blank.
Past Medical Conditions
Anything you've regularly seen a doctor for in the past.
If the answer is “non applicable”, please state “NONE” - don’t just leave the section blank.
VAT reg. no. 745 4115 43
Company no. 3884055
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