Medical Information Form

Current date ___________

Name_________________________________________
Age____
Birthdate ________
Emergency contact:______________________________ Phone:__________________

ILLNESSES/CONDITIONS: Please write yes or no and EXPLAIN yes answers:
Asthma____________________________________________________
Heart defect/disease_________________________________________
Seizures/headaches___________________________________________
Diabetes___________________________________________________
Musculoskeletal concerns______________________________________
Other illnesses or injuries that may affect ability to hike___________________
IMMUNIZATIONS - is DTP or tetanus up to date? _______________________
ALLERGIES which require special care?_______________________________
Do you carry Epipen or antihistamine with you? _________________________

Current Medications with dose & dispensing info. Indicate which ones you carry with you in your pack

____________________________________________________________

______________________________________________________________

Continue on back with any additional information helpful for providing emergency care.

Please fold & put in plastic zip lock bag and place in top pocket of your pack. This information is confidential and will only be used if you are injured on the trail and rescuers need access to this information to help you.

Please update when information changes.

Carry your insurance card with you.