Volunteer Health History Form

Name

Birthday

Gender

Age

Multi-line address

Country/Region

Address

City

Zip / Postal code

Primary phone

Secondary Phone

Family medical/Hospital insurance carrier

Policy or group number

Emergency Contact #1

Relationship

Daytime Phone

Evening Phone

Emergency Contact #2

Relationship

Daytime Phone

Evening Phone

Health History Record (check all that apply)

Any restrictions concerning physical activities?

Yes

Please describe any conditions

Allergies

Food/Nuts

Insect Stings

Medicine/Drugs

Other/Specify

Special dietary restrictions?

Date of last Tetanus booster (year)

Please list any medications taken on a daily basis, including over-the-counter medications

Any other relevant health concerns?

I verify that this health history is complete and accurate. I am able to engage in all prescribed activities, except as noted.

Signature

Date