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MEDICAL HEALTH & PERSONAL HISTORY
NAME:________________________ DATE OF BIRTH: _____________ AGE: ________
PHYSICIAN:__________________________________ PHONE:_____________________
INSURANCE:_________________________________ POLICY #: ___________________
PLEASE INDICATE CURRENT CONDITIONS:
Ear Infection Bleeding/clotting disorders Hypertension
Asthma Heart disease Muscular/skeletal Disorders
Seizures Diabetes Other
Describe details of current conditions: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PLEASE INDICATE ALL CONDITIONS SINCE LAST HEALTH EXAM:
Injury requiring medical attention any prescribed or over-the counter medication
Treatment in a hospital or emergency room Any exposure to contagious diseases
Any restrictions concerning physical activities Other
Please explain details of all conditions indicated above: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PLEASE LIST ANY FOOD ALLERGIES AND DIETARY NEEDS:
____________________________________________________________________________________________________________________________________________________________________________
OTHER HEALTH CONDITIONS AND PERSONAL HISTORY:
Hearing Impairment Glasses/contacts Emotional Disturbances Fainting Fear of water Fear of heights Motion sickness
Claustrophobic Discipline issues
Please explain any of the above:__________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
On a scale of 1-10, what is participants swimming ability:__________
DRUGS/PRESCRIPTIONS: Must be in the original container and labeled for the participant. No minors will be permitted to carry medication of any kind. All medicines must be turned over to the captain upon boarding.
Current Medications:___________________________________________________________________
Amount/frequency to be administered:____________________________________________________
Purpose:______________________________________________________________________________
Signature of applicant:_________________________________________
Dated:______________________
If under the age of 18
PARENT/GUARDIAN SIGNATURE:__________________________________________________
Dated:______________________
