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*may be answered by Jamie’s Whaling Station

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Medical Form

Please take your time filling out this secure form with honesty.

If you feel uncomfortable, you may always approach your guide or the owner privately before, or at the beginning of your tour to verbally address any medical concerns that you may have.

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Personal Information
Name*
First Last
Date of birth
Height*

Please include unit. For example: 5ft 9in or 1.75m
Weight*

Please include unit. For example: 180lbs or 81kg
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number (mobile preferred)*
Email*

Emergency Contact Information
Emergency Contact Name*
First Last
Relationship to participant*
Emergency Phone Number*
Family Doctor Name*
Family Doctor's Phone Number*

Physical and Mental Health:
Have you ever had, or are you prone to any of the following?
- Heart Condition
- High Blood Pressure
- Diabetes
- Chronic Headaches
- Asthma
- Overuse Injuries
- Depression
↳ Please provide detail
Within the last year, have you been treated or hospitalized for any of the following?
- Mental Illness
- Lung Disease
- Seizure
- Joint Dislocation
- Broken Bones
- Nose Bleeds
- Motion sickness / sea sickness
- Clinical Stress
- Surgery within the last year
- Other
↳ Please provide detail

Allergies:
Do you have any known allergies, or have you had an allergic reaction?*
- No
- Yes
↳ Is the reaction localized or systemic?
- Localized
- Systemic
↳ Please describe what causes the reaction, what it looks like, what happens before and after and how you treat the reaction.

Medications:
Are you currently taking any prescription or non prescription drugs?*
- No
- Yes
↳ What is the name of the medication(s)?*
↳ What is the dosage?*
↳ What is the condition you are treating?*
↳ Are there any effect if you miss a dose?*
↳ What are the effects if you take too much medication?*
If you are bringing medication with you:
- Bring twice as much as you are required to take for the entire length of the tour, pack it in two waterproof and UV proof containers and store it in an appropriate place
- List the name, dosage, frequency, instructions and expiry on the outside of each container.
- Give one container to your guide in case you lose or damage your own. Guides cannot administer medication.
- Make sure your medication has not expired.
- Discuss drug complications (i.e. Photosensitivity) and allergies with your guide.
- Bring all literature pertaining to your medication (i.e. the package, CPS information)
Please check to verify that you have read and understand the information above.*
- I have read and understand the information above

Recent Medical History:
Please check off if applicable
- Are you currently susceptible to infections?
- Have you had a serious illness in the last year?
- Do you smoke?
- Are you pregnant?
- Are you taking Birth Control?
↳ Please provide details*
Inoculations:
When was your last Tetanus Inoculation or booster?*

If you can’t remember please find out from your doctor and schedule a booster if needed upon the advice of your doctor

Eye Sight:
How would you rate your Eyesight without lenses?*
- Excellent
- Good
- Poor
- Very Poor
Do you wear eye glasses?*
- Yes
- No
Do you Wear Contact Lenses?*
***If you rely on corrective lenses it is recommended you bring a spare set as well as a means to secure them on your face and keep them floating.***
- Yes
- No

Fitness:
In my opinion, my current fitness level is*
- Excellent
- Good
- Poor
- Very Poor
Are you prone to getting cold easily?*
- Yes
- No
Do you have any physical or mental limitations that might impact your ability to participate fully in this sea kayak tour?*
- No
- Yes
↳ You selected yes, please provide an explanation

Kayaking Experience:
Have you been sea kayaking before?*
- No
- Yes
↳ When was the last time you kayaked?*
- Never
- Within the last 6 months
- Within the last year
- Between 2 and 5 years ago
- +5 years ago
↳ Have you ever performed a wet exit? (fallen out of sea kayak)*
- Yes
- No
Are you comfortable swimming 25 meters?*
- Yes
- No
- with a life jacket
Preferred Kayak Type*
- Single kayak
- Double kayak
- Doesn't matter
We cannot guarantee single kayak or double kayaks until the day of the tour. The decision is made by the guide and is based upon, group ability, weather and sea state conditions as well as safety ratios set by the industry....Do you have a preference for single or double sea kayaks?

Diet:
Do you have any specialized dietary needs?*
- Yes
- No
↳ Please describe in detail your specific needs so we can feed you well.

Paddle West Kayaking Online Medical Form Disclaimer and Privacy Statement
The personal information you provide on this form will help us better prepare ourselves and manage risks to help you remain healthy while you are on an multi-day kayak trip. Access to emergency medical services will be delayed when you are camping in remote wilderness areas. This information will remain confidential with Paddle West Kayaking Ltd. It is shared only with your Kayak Guide and the owner of Paddle West Kayaking, and in some cases Management staff. We do not trade or sell any information we collect from you on this form.
Please check to verify that you have read and understand the Disclaimer and Privacy Statement*
- I have read and understand the Disclaimer and Privacy Statement

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*may be answered by Jamie’s Whaling Station

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Jamie’s Whaling Station

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168 Fraser Lane, Ucluelet, BC
Local - 250.726.7444
Toll Free - 1-877-479-3232
*may be answered by Jamie’s Whaling Station

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