Medical and Physical Condition Standard Information Form
I (print name)____________________________________________ (client), as lawful
consideration for contracting with San Juan Sky Outfitters, LLC (guide), furnish the
following medical, health, and dietary information to the guide, which I state to be true
and correct, and accepting responsibility for failure to disclose any condition or not fully
stating such condition. I understand that I must furnish complete information to include
physician’s reports if the condition(s) would otherwise be considered to be detrimental to
my health if not disclosed. I will attach additional sheets if necessary to fully disclose my
condition(s).
Age_____________ Weight_____________ Height______________
Have you ever had or been diagnosed as having heart or coronary artery disease?
___Yes ___ No
Do you suffer from high blood pressure? ___ Yes ___No
Do you have any other condition that requires taking daily medications or carrying of
special medication or equipment? ___Yes ___No
Do you have any allergies (including allergic reactions to specific medications) or other
physical conditions that require attention or medication? ___Yes ___No
Do you have any dietary restrictions or allergies? ___Yes ___No
If you have answered yes to any of the above, please explain in detail any specific
instructions needed by the guide._____________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Emergency contact name:___________________________________________________
Relationship:_____________________
Phone:__________________________
Date signed:______________________
Client Signature:__________________________________
Street Address:___________________________________
City: __________________State: ______Zip:__________
Phone:______________________