Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
(###)
###
####
Best Time to Call
*
Morning (8a - 12p)
Afternoon (12p - 4p)
Evening (4p - 8p)
Anytime
Date of Birth
*
MM
DD
YYYY
First Emergency Contact
*
First Name
Last Name
Relationship to Contact
*
First Contact Phone
*
(###)
###
####
Second Emergency Contact
*
First Name
Last Name
Relationship to Contact
*
Second Contact Phone
*
(###)
###
####
Do you have specific food or nutritional requirements? *
*
Check all that apply.
If you checked any of the above, please comment:
Epilepsy
*
Bleeding/Clotting Disorder
*
Heart Attack
*
Heart Murmur
*
Asthma
*
Ephysema
*
High Blood Pressure
*
Diabetes
*
Hypoglycemia
*
Lung Disease
*
Siezures of Any Kind
*
Anaphylactic Shock
*
Other conditions we should know about?
*
If you checked YES to any of the above, describe your conditions:
Environmental Substances
*
Foods
*
Drugs
*
Insect Bites or Stings
Other
*
If you checked YES to any of the allergic reactions above, describe your conditions:
Do you carry an EpiPen?
*
Yes
No
Back
*
Knees
*
Hips
*
Ankles
*
Other
*
If you checked YES to any of the above, describe your conditions:
Shortness of Breath
*
Chest Pain
*
Leg Pain
*
Other
If you checked YES to any of the above, describe your conditions:
Are you taking any prescribed medications at this time?
*
Yes
No
If YES, please list each medication, dosage and condition being treated.
Please assess your physical fitness:
*
Excellent
Good
Average
Fair
Poor
Are you currently (or within the past two years) receiving treatment from a physician or other health care professional for any physical or physcological reason?
*
Yes
No
If you checked YES to any of the above, describe your conditions:
Date of your last tetanus shot?
*
MM
DD
YYYY
Have you ever been told that your snoring is serious enough that it can disturb others?
*
Yes
No
Do you use a CPAP machine?
Yes
No
If you answered YES, please describe:
Is there anything else you feel we should know about you (your history or any other physical or emotional conditions) to help us support you during your time with us? Please specify:
I authorize the Illuman Arizona staff to furnish the information that I have completed above to medical professionals providing me emergency care during this event.
*
