Appendix 3
Department of ……………………….., University of Hull
Personal Details (Confidential), for ______________________ Overseas Field Course
Name (exactly as on passport if trip is outside the UK):
Student Number:
Date of birth:
Student User Number
e-mail:
Address:
Home address if different:
Telephone:
Mobile:
Telephone:
Next of Kin:
Address:
Relationship:
Do we have your permission to contact this person in an
emergency?
Telephone:
Allergies (check with your GP if in doubt):
**Medical conditions (please provide any details of any
medication to be taken, including any incompatibility with
other medication):
Vaccinations:
Dietary restrictions:
Passport number:
*Date of expiry :
*Issuing office :
Nationality:
Competence in activities as relevant (swimming, boat
handling, diving, caving climbing etc.):
First-aid certification:
Previous travel abroad:
Is there anything else we should be aware of?:
Are there any situations you may have difficulty dealing
with such as flying?
No.
1
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Question
Have you suffered at any time from diseases of the heart and circulation including high blood
pressure, angina, chest pains and palpitations?
Have you at any time had significant surgery?
Have you suffered from or had to take medication for, asthma?
Have you ever had collapsed lung or pneumothorax?
Have you ever had any other chest or lung disease?
Have you suffered at any time from blackouts, fainting or recurrent dizziness?
Have you had regular ear problems in the past ten years?
Do you have an ileostomy, colostomy or ever had repair of a hiatus hernia?
Have you ever had epilepsy or fits?
Have you had recurrent migraines?
Have you ever had any other disease of the brain or nervous system (including strokes or
multiple sclerosis)?
Have you ever had any back or spinal injury?
Have you any history of mental or psychological illness of any kind? This would include a fear
of small spaces, crowds, or previous episodes of anxiety or panic attacks.
Have you any history of alcohol or drug abuse in the past five years?
Do you have diabetes?
Are you currently receiving medical care or have you consulted the doctor in the last year other
than for trivial infection or minor injury?
Have you ever been refused a diving medical certificate or life insurance or been offered
special terms?
Have you ever had, or been treated for, decompression illness?
Could you be pregnant or attempting to become pregnant?
Have you had a head injury with loss of consciousness in the past five years?
Do you suffer from Travel Sickness?
Do you have any allergies to any know drugs or any other allergies?
Do you have any back, knee or other joint problems?
D you have any injury, break or sprain
Do you have any other illness, medical condition or disability
Yes
No
If you have answered yes to any of the questions above, please give details in the box below. This will help us support
you (e.g. If you need a refrigerator for medicines, if you use an inhaler, if you carry adrenaline, if you think that anything
on the course may present difficulties). Occasionally, it may be necessary to obtain a doctor’s note, following positive
answers to these questions, prior to the trip.
The details you have supplied on this form will be held by the Course Leader and shared with the Disability Tutor. For
Emergency purposes a copy will be held by the University Safety Office for the duration of the course and destroyed
thereafter.
Whilst disclosure of all medical conditions is not compulsory, you must include on the form any condition or disability
which might affect your safety (or that of others) whilst away which may need specific treatment if you become ill or which
we may need to disclose to the travel insurance company. This information will not be disclosed to anyone else on the
course without your permission, unless an emergency makes it necessary to do so.
__________________________________________________________________________
OFFICE USE ONLY
Cross Checked with AIS
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