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:________


Phone: Home(______)__________________Work(______)__________________

In case of emergency, notify:_________________________

Relationship:_____________________   Phone: (____)__________________

Family Doctor:_________________________________   Phone:(____)___________________
Health Insurance Company:____________________________   Policy #:________________________
(
If applicable) Auto Insurance Co.:_____________________   Policy #:_________________

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)

 

 

 

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