Core Medical Information

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CORE MEDICAL INFORMATION
FIRST NAME:______________________________ LAST NAME:________________________ CLASS______________
BIRTHDATE:______________HEIGHT:____
____
WEIGHT:_______
BLOOD PRESSURE:_____ /_____
inches
feet
pounds
CURRENT HEALTH STATUS: Please complete the following information to the best of your ability and knowledge.
Please indicate any medical conditions or physical issues that would interfere or limit your participation in the trip. If you are
unsure, please consult your physician for advice. None of these will necessarily prohibit your participation, but your honest
communication of the requested information is highly important and useful to prevent, prepare for and to handle any
emergencies. If you answer yes to any of the below, please specify in detail indicating the item number.
YES NO
YES NO
12.   Joint problems? (knees, ankles, hips, etc.)
1.   Hearing or vision problems?
13.   Frequent muscle cramps?
2.   Allergies?
14.   Serious reaction to high/low temperatures?
3.   Respiratory problems?
15.   Surgeries in the last six months?
4.   Heart problems or high blood pressure?
16.   Serious Illness/Hospitalizations in last year?
5.   Chest pain with physical exertion?
17.   Psychological or emotional problems?
6.   Seizure disorders?
18.   Do you smoke?
7.   High or low blood sugar?
19.   Are you pregnant? If yes how many months?
8.   Anemia, bleeding tendencies or traits?
20.   Have you ever had a heart attack or stroke?
9.   Diabetes?
Which/When?
10.   Back problems?
21.   Other conditions? Please explain
11.   Dislocations?
CURRENT HEALTH ISSUES: Please include a complete descriptions of any of the items checked yes above.
None
Item#
Detailed description: (include restrictions if any)
ALLERGIES: Please indicate any allergies you have your allergic reactions, and any required medications.
None
Allergies
Reaction
Medication Required (if any)
Rx?
Peanut Products
Yes No
Yes No
Insect Stings(bees, wasps)
Yes No
Yes No
Iodine or Shellfish
Yes No
Yes No
Yes No
Yes No
Yes No
DIETARY RESTRICTIONS: (Vegetarian, vegan lactose intolerant, kosher, etc. Please indicate specific restrictions).
None
MEDICATIONS: Please indicate any medications you are currently taking (other than those listed in the allergy section.), for what condition, and
None
whether you will need it for the trip. Please be certain you have ample supply.
Medication
Condition Under Doctor’s Supervision
Do you need this during trip?
Yes
No
Yes
No
Yes
No
REQUIRED IMMUNIZATIONS: Please be certain to update your tetanus booster.
Immunization
Required Interval
Last Immunization
Exemption
Tetanus
Within 10 years of trip end date. Recommended within 5 years.
Religious

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