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Iowa BOW - Medical History Questionnaire
Please note, all information is confidential. It will only be used in the case of emergency while attending the 2022 Iowa Becoming an Outdoors-Woman workshop at Wesley Woods in Indianola, IA.
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* Indicates required question
Email
*
Your email
What is your full (given) name?
*
Your answer
What is your date of birth?
*
MM
/
DD
/
YYYY
What is the name of your regular doctor? Please include phone number if known.
Your answer
Do you have any allergies?
*
Yes
No
If yes, please list. i.e. bee stings, garlic, penicillin, etc.
Your answer
Do you take any medication?
*
Yes
No
If yes, please list:
Your answer
Have you ever been told by a doctor that you have epilepsy?
*
Yes
No
If yes, when?
Your answer
Have you had any recent surgical operations, accidents or injuries?
*
Yes
No
If yes, when and please describe:
Your answer
Have you been "knocked out" unconscious, had a concussion or head injury?
*
Yes
No
If yes, when and please describe:
Your answer
Are you pregnant?
*
Yes
No
Do you have any medical training?
Doctor
Nurse
Emergency Medical Technician
Other:
Clear selection
Please list a name and phone number(s) of a person to contact in case of an emergency.
*
Your answer
Is there anything else about your health you would like us to know in case of emergency?
Your answer
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