The completion of this form is optional; however, please note that in the case of a medical emergency this information would be critical to ensure that you receive the most appropriate medical care.

If you'd prefer to complete the Medical Information Form and submit via mail or email, please use this PDF.

Participant name(Required)

First Last

Age

Please enter a number from 0 to 110.

Name of emergency contact

Emergency contact phone number

Alternate phone number

Allergy Questions

Do you have any allergies?(Required)

Yes

What medication allergies do you have?

What food allergies do you have?

What other allergies do you have?

General Health Questions

Do you have any ongoing medical conditions?(Required)

Yes

Please specify below:

Asthma

Diabetes

Seizures

Heart Condition

High Blood Pressure

Other medical conditions

Have you been hospitalized within the last year?

Yes

What were you hospitalized for in the last year?

Do you wear glasses or contacts?

Yes

Do you wear hearing aids?

Yes

Please describe the assistive devices you use (i.e. wheelchair, toilet riser, grab bars, etc.).

Current Medications

List your medications below.

Medication name

Dose

How often

Medical Information Form

RVRC Medical Information

Allergy Questions

General Health Questions

Current Medications

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