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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)

 

  • Physical disabilities or limitations                                                                              Yes      No

  • Dizzy spells, fainting, convulsions, persistent headaches                                        Yes      No

  • Shortness of breath or chest pain                                                                               Yes      No

  • Heart, circulatory or blood pressure problems                                                          Yes      No

  • Back, neck, knee or skeletal problems                                                                        Yes      No

  • Operations/major medical procedures in the last year                                             Yes     No

  • History of serious illness.  Hospitalization required?                                                 Yes     No

  • 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***