Medical Form

Date / MM / DD YYYY
Name First Last
Date of Birth / MM / DD YYYY
Sex Male Female
Weight (lbs or Kg)
Height (cm or ft)
Principal Health Care Plan

If this information is not known at the time of registration please inform us as soon as possible. We require proof of coverage before departure.
Plan Number

If this information is not known at the time of registration please inform us as soon as possible. We require proof of coverage before departure.
Extended Insurance

If this information is not known at the time of registration please inform us as soon as possible. We require proof of coverage before departure.
Plan Number

If this information is not known at the time of registration please inform us as soon as possible. We require proof of coverage before departure.
Physician's Name
Physician's Phone
Emergency Contact
Relationship
Phone (h)
Phone (w)
Do you have any allergies to food, medications, or environmental triggers?
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Allergy
Describe Reaction and Severity
Management
2
Allergy
Describe Reaction and Severity
Management
3
Allergy
Describe Reaction and Severity
Management
4
Allergy
Describe Reaction and Severity
Management
Are you on any medication? Please list all prescription, non-prescription, and vitamins. (include: dosage & purpose)
Date of last Tetanus Immunization / MM / DD YYYY
Please describe your overall general health
Are you under the routine care of a doctor for any chronic conditions or diseases?
List Previous Surgeries
Previous Hospitalizations
Major Injuries
Women, are you pregnant Yes No
Please circle any of the following conditions that you may have. Describe your condition in detail in the space below if necessary. Diabetes Cardiac Disease High Blood Pressure Stroke Seizures Gastro-Intestinal disease Lung Disease Kidney problems Cancer Thyroid Dysfunction Migraines Liver problems Blood or Bleeding problems Musculoskeletal disorders Mental Health Problems
Please rate your physical fitness Poor Fair Good Excellent
Is there anything else not listed or described above that you feel we should know about your health?
I have completed this form as accurately as possible and is complete to the date signed below. I agree to notify/update Cabin Fever Adventures of any changes or new developments in my physical health in the period between the completion of this form and the start of the trip. * Poor Fair Good Excellent

Medical Form

Medical Form

Do you have any allergies to food, medications, or environmental triggers?

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