Medical Form

This form must be completed and validated by your doctor to be allowed to participate to our vayage and expeditions on board the yacht Argonaute III.

Name______________________
Birth date______________________
Comapny______________________
Address: _____________________________________________________
Email: _____________________
Telephone _______________
Birth date _______________
Sex: ____, height ______m, Weight _____Kg

In case of emergency, person to advice:

Name:  _____________   Tel. (day)___________Tel (Night): _____________
Fax: ______________ Email________________  Kinship: ______________

 

Medical profile: 

For the following questions please comment any time you answer by a YES.

Do you have presently any medical problem: __________________________________

Have you or has anybody diagnose any of the following problems high blood pressure, high cholesterol, epilepsy, diabetes, AIDS, asthma, lung disease, back problems, arthritis or balance problem or any other illness?

_______________________________

_______________________________

_______________________________

___________________________________

Have been treated for drug or alcohol use or abuse? 

________________

Have you got any allergy (take into account allergy to medicine drugs, (please detail)) 

________________________

 

Have you got allergy to any type of food, or do you follow a particular diet - including religious diet -

________________________
Have you been hospitalized during the last four years?______________
Do you follow a regular  medical treatment?   ________________
do you suffer from any particular gastric problem, ulcer... _________________
Did you already suffer from the seasickness?: _______________
Does your seasickness disappear after few days of sailing?:  _______________
Did you received already a psychiatric treatment?_______________
Do you follow a treatment against depression?: _______________
Or any king of psychological problem:  _______________

Your doctor direction:

Name_______________
Address__________________________________
Email: _________________________
Telephone :   ______________________________

 

Insurances:

I understand and accept that the medical treatment and emergency evacuation may be very expensive and will be my complete financial responsibility. I also understand the utmost importance of travel , and  medical accident insurance while traveling in foreign countries and i take full responsibility. I accept de ask for medical assistance if the skipper captain decides it is better for me, and will assume total financial responsibility.

My personal insurance covers travel accident and sickness and medical evacuation over the regions where I will be sailing with the Argonaute. 

Signature: _________________________

Swimming certificate

While sailing, the possibility to fall over board is always present. In such a case the ability to swim is vital for your survival.

I certify by signing this letter that I can swim comfortably:

  1. At least 20 mn in a moderate sea
  2. A least 50meters in a moderate sea.

Signature                                 date 

 

 

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