Confidential Medical Information     

This form is a request for information regarding any past or current medical condition/s you may have or had. The information provided here is confidential and is for the exclusive use of your guide/s and care providers.

First/Last Name:_______________________       DOB: ___/___/___

Medical History:

Are you currently prescribed any medications?  YES            NO

                If yes, please list these medications?__________________________________

                ________________________________________________________________

                Do you carry any of these medications with you?________________________

Do you take nitroglycerine for high-blood pressure? YES     NO
                Did you bring nitroglycerine with you? YES            NO

Have you been admitted to the hospital or emergency room in the past two years?    YES         NO                                                                                                                                  

                If yes, please describe.___________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

Please list any medical conditions you may suffer from that are not listed above._______

________________________________________________________________________________________________________________________________________________

Allergies:

 

Are you allergic to any medications? YES              NO

                If yes, please list these medication/s.____________________________________

                __________________________________________________________________

Do you have any allergies to food/s or insect/s?   YES          NO

                If yes, please list.____________________________________________________

                __________________________________________________________________

                Do you carry epinephrine? YES             NO

Do you carry an inhaler for asthma or respiratory assistance? YES        NO

Have you been diagnosed with epilepsy? YES      NO

                If yes, when was your last epileptic episode?______________________________

Are you Diabetic? YES           NO
                If Yes, what do you carry with you for assistance?_________________________

                _________________________________________________________________

Please list anything you think might help your guide/s in the case of an emergency.

________________________________________________________________________________________________________________________________________________

The above information is true to the best of my knowledge, I have not neglected to mention any medical condition/s or allergy/s I currently suffer from or have had problems with in the past. I release this information to my primary care providers in the case of an emergency.

Signature x________________________________________________                           Date ___/___/___