Asthmatic Questionnaire

Asthma Questionnaire

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Explorer's Details

Name:

School:

Expedition code:

Destination & Year:

Date of birth:

I confirm that my child:

When was your child's last attack?

What normally causes the attacks?

What preventative medication/inhalers does your child use?

What reliever medication/inhalers does your child use?

Please indicate frequency of use during normal daily activities e.g. once a day, once a week etc:

Please indicate frequency of use during routine exercise:

Has your child ever required hospital admission for your asthma?

If ‘YES' please give details (including dates):

Have you sought advice from your child's doctor or hospital prior to completing this health declaration?

If ‘YES’, what did the doctor/specialist advise?

Do you have any additional comments or declarations to make regarding your child's health or asthma?

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Important:

I fully understand that adventurous training is a strenuous activity which may be undertaken in extremely cold and additionally, at times, in a “freezing fog” type atmosphere. Additionally, I confirm that if I am unsure about my child's suitability to take part in this expedition I should seek advice from my child's doctor or asthma nurse before signing this declaration. Should my child's asthma condition change, before arriving for activities requiring any amendment to the above questionnaire, I will advise the person in charge immediately.

Parent/ Guardian signature:

Student signature:

Date:

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Declaration

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I confirm that the information provided by me is to the best of my knowledge true & correct

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Adventure Lifesigns reserves the right to withdraw participants from the expedition if any information is found to be false.