Participant’s Medical Information MedicalΔ First NameLast NameEmailPhone/MobileHave you previously or do you currently have:Low or high blood pressure Yes NoAsthma Yes NoDo you carry an inhaler? Yes NoBack problems Yes NoPlease describe back problemsKnee problems Yes NoPlease describe knee problemsDizziness, fainting spells Yes NoSevere abdominal or menstrual cramps Yes No n/aEmotional impairment or disability Yes NoImmunizations current? Yes NoThyroid trouble Yes NoEpilepsy or convulsions Yes NoADD or ADHD Yes NoAre you currently pregnant? Yes No n/aAre you presently using any medicines, alcohol, or drugs? Yes NoPlease list medicines or drugsHeart Problems Yes NoPlease list heart problemsAllergies Yes NoPlease list allergiesDo you require an epipen? Yes NoRecent sprains, fractures, or dislocations Yes NoPlease describe sprains, fractures, or dislocationsDiabetes Yes NoType/TreatmentCurrent communicable diseases Yes NoPlease describe communicable diseasesDate of BirthHeightWeight (LBS)Sex Male Female Other Rather not sayDietary Restrictions/Food AllergiesInsurance CarrierPolicy NumberDoctorCityPhoneEmergency Contact #1RelationshipPhone/MobileEmergency Contact #2RelationshipPhone/MobileSubmit Form
