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Medical Form
Medical Form for adult volunteers
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* Indicates required question
Email
*
Your email
today's date
*
MM
/
DD
/
YYYY
Your Name
*
Your answer
Birth date
*
MM
/
DD
/
YYYY
Your Address
*
Your answer
Emergency Contacts: Name and Phone #
*
Your answer
Insurance Company and Policy # and Group #
*
Your answer
Allergies
*
Yes
No
Asthma
*
Yes
No
Diabetes
*
Yes
No
Kidney Problems
*
Yes
No
Heart Problems
*
Yes
No
Epileptic
*
Yes
No
Pregnant
*
Yes
No
Maybe
Sickle Cell Anemia
*
Yes
No
Maybe
Stomach Issues
*
Yes
No
Nervous System Disorder
*
Yes
No
Muscle Disease Disorder
*
Yes
No
Bleeding or Clotting Disorder
*
Yes
No
Any Serious Injuries or illness
*
Yes
No
Do you wear glasses or contacts?
*
Yes
No
Any history of mental/emotional health counseling or hospitalizations?
*
Yes
No
If you answered YES any where above, please explain.
Your answer
List any medications needed for the trip. Include type, dosage and time needed to be taken.
*
Your answer
List any physical limitations
*
Your answer
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