Antietam CreekConfidential Med Form
CONFIDENTIAL MEDICAL INFORMATION
If you take medications for allergies bring them with you to the training course.
(Please print clearly)
Name of participant_________________________________________ Male ______ Female ______
Address ____________________________ City ______________ State/Zip ______________
Home Phone _____________________ Work Phone _____________________
Age _____ Height _______ Weight ______ Hair Color __________ Eye Color _________
Health ins provider ________________________ Policy # ____________ Group # _________
Emergency Contact: __________________________________ Relationship _______________
Home Phone _____________________ Office Phone ________________________
Name of personal physician ___________________________ Phone _____________________
Allergies _____________________________________________________________________
Current Medications ________________________________ Year of last tetanus shot ________
Swimming ability _______________________________________________________________
Have you had or do you currently have any of the following: (Circle Yes or No)
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Physical disabilities or limitations Yes No
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Dizzy spells, fainting, convulsions, persistent headaches Yes No
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Shortness of breath or chest pain Yes No
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Heart, circulatory or blood pressure problems Yes No
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Back, neck, knee or skeletal problems Yes No
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Operations/major medical procedures in the last year Yes No
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History of serious illness. Hospitalization required? Yes No
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Emotional/mental disorders Yes No Any other medical/health conditions which may impact your participation in
strenuous outdoor activities Yes No
If you answered Yes to any of the above, please explain in detail (use back of page if necessary):
______________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Additional Info helpful in an emergency _____________________________________________
In addition, I authorize Kenneth A. Guerrant to act on my or my minor child’s behalf in obtaining medical treatment if I am unable to in the event that I become injured or ill while participating in this program; and I understand that I am fully responsible for all expenses incurred for any medical care received.
Signature ________________________________________________ Date ________________
(Parent must sign if student under 18)
***This form must be given to the instructor at the first class or outing***