Personal Medical History

*Please provide the following information.  ALL areas must be completed

Your Name:______________________________________________Date of Birth:_________                  
Address:______________________ City:________________State:_______ Zip:__________           
Emergency Contact:______________________Contact Phones:_______________________

Cell________________        Passport number________________________           

Special dietary Needs__________________________________________________________ 
                                                                                                                       
Medical Insurance_____________________________________________________________
Insurance company phone number:_______________Policy #:_________________________               
Allergies_____________________________________________________________________
Medication for Allergies:________________Frequency_______________________________

     Asthma                        Y   N                 Diabetes                     Y   N 
     Hemophilia                   Y   N                 High Blood Pressure     Y   N
     Cancer                         Y   N                Migraine Headaches      Y   N
     Colitis                           Y  N                Ulcers                           Y   N
     Epilepsy                       Y   N                Heart Disorder               Y   N
     Tetanus Shots Current   Y   N                Hepatitis A                    Y   N      Hepatitis B   Y  N

Provide an explanation for any yes answers above and how you manage the condition now.                                                                                        

Please list and explain any other illness not mentioned above:                                                                                                

Injuries                               Y   N                          Head injury          Y   N
Reoccurring ankle sprain      Y   N                          Back injury          Y   N
Knee injury                          Y   N                         Broken bones       Y   N
Other: _______________      
Please explain any YES answers above:                                                                                                        
Medications:

Please list every medication you take.  Include the name of the medicine, dose and how often you take it.
Medication:
           
            *Dosage
           
           
            *Frequency
           
            This information is complete to the best of my (our) knowledge:

            Signature of Parent(s)/Guardian(s) __________________________Date______________                        
            Signature  of participant___________________________________Date______________