IN CASE OF EMERGENCY
HEALTH INSURANCE INFORMATION
CURRENT PHYSICAL CONDITION. Please check the highest activity level in each category that you feel you can comfortably (and honestly) attain.
If yes, list activities or sports you engage in, intensity, times per week, and duration.
CURRENT HEALTH STATUS
ALLERGIES: Please indicate any know allergies that you have (medications, foods, etc.). Also list any allergic reactions and medications required.
DIETARY RESTRICTIONS OR FOOD ALLERGIES: Please indicate specific dietary restrictions.