MEDICAL QUESTIONNAIRE and INFORMED CONSENT PERSONAL INFORMATION Full Name: Jefferson Kevin R.

Morco Nickname: Jeff Home Address: 2865 Rizal Avenue St. Sta. Cruz Manila, 1014 Philippines Telephone : (02) 740 57 05 Birth Date: August 12, 1991 Age: 22 Company Name: HONS Surveying Position : Cad Operator Co. Address: Telephone EMERGENCY INFORMATION Contact Name : Ronalice Clare G. Angcao

Telephone: +63 917 530 3532

PHYSICAL CONDITION Please answer all of the following questions: 1. Have you been told by a physician or are you aware of any medical conditions (such as heart disease, high blood pressure, diabetes, asthma, pregnancy, seizure disorder, anemia, hernia or others) that could be aggravated by physical activity? Yes __ No  If yes, please indicate _____________________________________________ 2. Have you been told by a physician or are you aware of any neck, back, shoulder, wrist, hip, ankle, knee, tendon, ligament problem, fracture or any other muscular or skeletal problem that may be aggravated by physical activity? If yes, are you using any orthopedic device for this illness? Yes __ No  If yes, please indicate _____________________________________________ 3. Have you ever had surgery? What kind? When? Yes __ No If yes, please indicate _____________________________________________ 4. Has a doctor ever denied or restricted your participation in sports for any reason? Yes __ No If yes, please indicate _____________________________________________ 5. Have you ever passed out or nearly passed out during or after physical activity? Headache with physical activity? Yes __ No  If yes, please indicate _____________________________________________ 6. Have you been told by a physician or are you aware of other medical or physical problems which you think we should be told about before the activities begin? Yes __ No  If yes, please indicate _____________________________________________ 7. Have you ever had chest pain, discomfort, tightness during a physical activity? Yes __ No  If yes, please indicate _____________________________________________ 8. Do you have sensory difficulties, such as poor eyesight or impaired hearing? Yes __ No  If yes, please indicate _____________________________________________ 9. Do you have any allergies? Yes __ No  If yes, please indicate _____________________________________________ 10. Do you have a special diet? Yes __ No  If yes, please indicate _____________________________________________ 11. Are you under medication at present? Yes __ No  If yes, please indicate _____________________________________________ 12. If not under medication at present, within the last 2 weeks? Yes __ NoIf yes, please indicate _____________________________________________ 13. Do you have a history of emotional, psychological or psychiatric problem of any sort? If yes, did you seek any clinical or medical attention? Yes __ No  If yes, please indicate _____________________________________________ 14. Have you ever been hospitalized? When? Why? Yes __ No  If yes, please indicate _____________________________________________ INFORMED CONSENT I acknowledge that I have been given the opportunity to participate in StrataAsia Consulting Inc.’s activities and I have been advised that I can decline if I wish. I understand that my participation in any part of or all of said event is voluntary and I can decline to participate in all of, or any part of, the activities. I further acknowledge that every part of my participation involves physical activities, and that the potential exists for personal injury. I will not now, nor during my participation, be under the influence of alcohol or any chemical substance, except as disclosed on this Participant’s Questionnaire. I hereby waive and release all rights and claims which I may have against StrataAsia Consulting Inc., its staff, employees and its agents for any and all injuries or damages suffered by me while participating in this activity, EXCEPT, to those that apply to injuries or damages caused by gross negligence or willful misconduct by StrataAsia Consulting Inc., its staff, employees or its agents. Signed, ____________________________________ SIGNATURE OVER PRINTED NAME

_____________________ DATE

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