ADULT HEALTH HISTORY

Name
Home Phone  
Address 
City  State Zip

EMERGENCY CONTACT:

Name
Home Phone  
Address 
City  State Zip
Physician 
Phone
Insurance Carrier
Policy #

Date of last health exam

Please specify any medical problems noted:



Are you under care for a medical condition? Please specify:



Do you take medication on a regular basis? Please specify:



If you have any ALLERGIES, please indicate source and treatment needed



Any other health conditions?



Date of last tetanus immunization (should be within 7 years)

PERMISSION TO TREAT
In case of emergency, and the designated emergency contact listed above is not available, the following person is authorized to act in my behalf.

Name
Home Phone  
Address 
City  State Zip
Relationship

If neither person is available, the first aider or another adult in the group has my authorization to act on my behalf.

____________________________ Signature