Medical

Medicla Notes
Medical Notes go here about any concerns that are found during the medical review.
Name*
First Last
Phone*
Date of Birth*
Date Format: MM slash DD slash YYYY
Age*
Height*
Feet/Inches
Weight*
In lbs.

Current Medical Treatments*
Lst of conditions you have or are being treated for. If you have no medical condition or treatments enter "None".
Blood Pressure
Please list your Blood Pressure and Resting Pulse Rate (if known):

Allergies?*
Any allergies or sensitivities to insect bites or stings that could result in anaphylactic shock.
- Yes
- No
If YES, please explain allergic condition:

Food Allergies*
Any allergic reactions to any environmental substances, food or drugs
- Yes
- No
If Yes
If yes, please explain allergic reaction(s)

Back, Knees, Hips, or Ankles*
Any problems or disabilities with the back, knees, hips or ankles?
- Yes
- No
Yes
If YES, clarify limiting condition

Lungs & Breathing Condition?*
Have you ever had a lung disease? (asthma, emphysema, sleep apnea, etc.)
- Yes
- No
If YES
If YES, please explain your respiratory condition and requirements (if any):

Walking a Mile*
If you walked on the level for a mile at an average pace, would you get out of breath, have chest pain or leg pain, or develop muscle fatigue?
- Yes
- No
If YES
If YES, your walking condition:
Date of Last Tetanus Shot*
If you do not know the date (or year ago) of your late Tetanus shot, state: "I don't know"
Current Physical Fitness
How would you rate or describe your present degree of physical fitness?

Medical Treatment in Past 2 Years*
Are you currently (or within the past two years) receiving treatment from a physician or other health care professional for any physical or psychological reason?
- Yes
- No
If YES
If YES, briefly explain you treatment

Perscribed Medications*
Are you taking any prescribed medications at this time?
- Yes
- No
If YES
If YES, please specify the medication, dosage, and the reason for which it was prescribed.

Anything Else*
Is there anything else you feel we should know regarding your physical/emotional condition and/or history to help us be of better service to you on your vision quest?
- Yes
- No
If YES
If YES, please explain

First Emergency Contact*
This is the first person we will call in case of an emergence. It required to have someone who knows your medical history listed hear and they know they are your contact for this event.
First Last
Relationship*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*
Work Phone
Second Emergency Contact
This is the second person we will call if your first emergency contact is not reached. Second Emergency Contact is Optional but encouraged.
First Last
Relationship
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Work or Other Phone to Call Cantact
Insurance*
Medical Insurance if no insurance enter: None
Policy Number*
Medical Insurance Policy Number, if no insurance enter: None
Insurance Phone
Insurance Company's Phone Number.
Email
This field is for validation purposes and should be left unchanged.