Medical History Form

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Medical History Form

Name of Participant

Please include your FIRST and MIDDLE name in first block.

First Name

Last Name

Cell Phone Number

(###)

###

####

Parent/Guardian Email

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Age

Medical Alert

Emergency Contact #1

Emergency Contact #1 - Phone Number

(###)

###

####

Emergency Contact #1 - Relationship to Participant

Emergency Contact #2

Emergency Contact #2 - Phone Number

(###)

###

####

Emergency Contact #2 - Relationship to Participant

Primary Care Physician

Primary Care Physician - Phone Number

(###)

###

####

Health Insurance Provider

Health Insurance Policy Number

Please list any major medical history problems you have had in the past 5 years.

(operations, traumas, illnesses, psychiatric conditions, and/or psychological conditions)

Please list any injuries or illnesses that you are currently receiving treatment and/or medication for along with how it may affect your participation.

Please list any current medications along with dosing and timing.

Please list any allergies and how they affect you.

(medications, foods, plants, animals, insects, other)

Please list any special dietary needs.

Please list any other concerns or conditions that may affect you or your group's performance in a wilderness context.

Medical History Form

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11 State Route 50, Glorieta, NM 87535
Mailing Address: PO BOX 203071, Austin, TX 78720

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Medical History Form

11 State Route 50, Glorieta, NM 87535Mailing Address: PO BOX 203071, Austin, TX 78720

11 State Route 50, Glorieta, NM 87535
Mailing Address: PO BOX 203071, Austin, TX 78720