Medical History Form
This form is essential for your safety and enjoyment of the trip. Please take time to fill out completely, accurately, and return promptly.
Please DO NOT mail this form. Bring it to the first day of camp.
Course Name: ________________________ Course Date: ________ AM:_ PM:_
NAME: __________________________ Sex: __ Date of Birth: ___________
Address: Email:__________________________
City: ____________ State: ___ Zip:________
In case of emergency, notify:_________________________
Relationship:_____________________ Phone: (____)__________________
Family Doctor:_________________________________ Phone:(____)___________________
Health Insurance Company:____________________________ Policy #:________________________
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Medical History
Are you allergic to any of the following? (check if "yes")
| Insects___ | Aspirin____ |
| Penicillin____ | Food (please name type)____ |
| Other____ | Medication(please name type)____ |
Clothing: |
|
| Wool____ | Cold____ |
| Down____ | Other allergies (please list) |
If yes to any of the above, please describe your allergic reaction and how you treat it:
Do you have a history of (check if "yes"):
| Frostbite___ | Asthma(cold induced)____ |
| Hypothermia____ | Asthma(excercise induced)____ |
| poor circulation____ | abnormal blood pressure____ |
| knee or other joint problems____ | seizures____ |
| toothaches____ | diabetes____ |
| stomach problems____ | dizziness____ |
| bronchitis____ | migraines____ |
| arthritis____ | eyestrain (light sensitive)____ |
| unconsciousness____ | past surgery____ |
if yes to any of the above, have you been treated? Explain.
Are you still on medication? Explain:
Have you taken or do you presently take any medication on a regular basis? If yes, describe:
Do you use a corrective brace or device?________
Is there anything which we should know about you? (Phobias, special sensitivities, ect.)
Do you require a special diet? If yes, please explain:
I have answered the above questions accurately and completely.
The staff of Olympic Outdoor Center has permission to seek and/or administer emergency care for the participant in the event that the participant or guardian cannot respond at the time of emergency.
Date: __________________ Signature of participant:_________________________
Date: __________________ Signature of parent/guardian:_______________________
(if participant is under age 18)