Please Complete: Health Form Adult Health Form Save my progress and resume later | Resume a previously saved form Resume Later In order to be able to resume this form later, please enter your email and choose a password. Your Email: A Password: Confirm Password: Page 1 Your Name: Allergies Do you have any allergies (drug, food, environmental, or other)?YesNo Do you have any systemic reactions to insects or bee/wasp stings (i.e.: swelling, rash, or difficulty breathing)?YesNo Is an EpiPen required for any allergy? (Note that VISIONS does NOT provide EpiPens on programs)YesNo Are you allergic to sulfa drugs? (Diamox and other sulfa drugs are sometimes used to treat altitude sickness)YesNo If yes to any of the above, please provide a list of the allergy, reaction, and treatment Please provide any additional information regarding allergies, or note any suspected allergies that are not listed above. Important: If you have known or suspected moderate to severe allergies, you must bring an EpiPen. VISIONS does not provide EpiPens. Asthma/Respiratory Problems Do you have any past of ongoing asthma or respiratory problems?YesNo VISIONS requires anyone with asthma or respiratory issues to bring with them the medications and associated devices (i.e.: inhaler, nebulizer, spacer, etc.) for all status levels, including: daily (green), caution (yellow), and emergency (red). We recommend bringing multiple emergency inhalers, depending on the severity of the case. List any triggers and symptoms, along with associated medicines, dosages, and steps to take in the case of distress. Have you been hospitalized as a result of asthma or respiratory problems? YesNo Please provide the dates of and reason for hospitalization Food/Diet Do you have any dietary restrictions not relating to allergies?YesNo Please provide details, including the specific restrictions and if the reasons are religious, medical, or other Physical Restrictions Do you have any physical limitations that require consideration or assistance?YesNo Do you have any cognitive or sensory conditions that require consideration?YesNo Do you have any activity restrictions? YesNo Please provide details, including the specific restrictions and/or considerations Any other health information that may be relevant during the program? This may include past surgeries, GI illnesses, heart disease, blood clotting issues, concussions, chronic or recurring illnesses, communicable diseases, and anything else you feel comfortable disclosing and that could be useful in having be part of your record in case of a medical situation or emergency. Record ID Contacts and Insurance First Emergency Contact Emergency Contact Name Relationship Phone 1 Phone 2 Second Emergency Contact Second Emergency Contact Name Relationship Phone 1 Phone 2 Medical Providers(This section is optional) Physician Name Name of Physician's Practice Physician's Phone Number Dentist Name Name of Dentist's Practice Dentist's Phone Number Other (for example, psychotherapist) Other Practice Name Other Field of Practice Other Phone Number Health Insurance(This section is optional) Policy Holder Name and Address Insurance Company Name Group Insurance Name (employer, union, association, or n/a) Policy Number Group Policy Number Insurer Address City State Postal Code Save my progress and resume later | Resume a previously saved form Contact Information
