Green Mountain Rock Climbing Medical History/Emergency Contact Form

Part 1 – Participant Information

Name: _______________________________________             Date of Birth: ____________
Height: ___________________       Weight: ____________ lbs.      Foot Size: ___________
In case of Emergency, contact: ____________________________________________
Phone: _____________________            Relationship to you: __________________________

Are you covered by any hospitalization/medical care policy? Yes No
Insurance Company Name: _______________________ Policy Number: ____________

Part II –Medical History
Allergies (including medicines, foods, bites/stings, etc.)
_______________________________________________________________________
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Medications (list any and all medications you are using, including over-the-counter
medications. Identify the medication name and dosage, what it is for, and how often you
take it.)
________________________________________________________________________
________________________________________________________________________

Hospitalizations, Emergency Room and/or Medical Center Visits
(List all visits in the last two years, the date, and the treatment you received).
_______________________________________________________________________
_______________________________________________________________________

Current Exercise Activity:
Activity(s): ________________________________________________
Frequency: (days/week) ___________________________________
Intensity: low/mod/high_____________________________________

Part III –Past and Present Medical Conditions
(Name: ______________________)
Fill in EVERY blank. Use additional pages if necessary.

Do you currently have, or within the past five years, have you ever had…
                                                                                              Yes              No
High Blood Pressure Stomach ulcers                                   _______     _______
Irregular or rapid heartbeat                                                  _______     _______
Intestinal problems                                                               _______     _______
Family history of heart disease                                            _______     _______
Bladder Infection                                                                  _______     _______
Blood disease                                                                      _______     _______
Kidney problems                                                                  _______     _______
History of hepatitis                                                               _______     _______
Hearing impairment                                                             _______     _______
Bleeding disorder                                                                _______     _______
Vision impairment                                                                _______     _______
Seizure disorder                                                                  _______     _______
Motion sickness                                                                   _______     _______
Seizure within past year                                                      _______      _______
Sleep walking                                                                      _______     _______
Headaches Broken bones                                                   _______     _______
Respiratory problems                                                          _______     _______
Neck or back problems                                                        _______     _______
Chronic cough                                                                     _______     _______
Shoulder problem                                                                _______     _______
Asthma Knee problem                                                         _______     _______
Diabetes Ankle problem                                                      _______     _______                         
Hypoglycemia                                                                      _______     _______
Hand/foot problem                                                               _______     _______
Frostbite                                                                              _______     _______
Currently pregnant                                                              _______     _______
Poor circulation or Raynaud's                                             _______     _______
Other intolerance to cold temperatures                               _______     _______                         

I would prefer my physician's advice prior to participating in this course ? (Circle)          YES        NO

If you answered “yes” to any of the above items, please explain below.
Include the following:
• Identify if this condition results in any restrictions in your ability to perform a task: ____________________
_____________________________________________________________________________________
• What specific symptoms have you experienced?______________________________________________
_____________________________________________________________________________________
• How often do symptoms or the conditions occur?______________________________________________
_____________________________________________________________________________________
• How do you care for the symptoms/condition?________________________________________________
_____________________________________________________________________________________

Detailed Description (If Necessary):

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