Medical History Form You can also download and print the form Participants Name(Required) First Last Date(Required) Date you are scheduled to climb(Required) DO YOU SUFFER FROM ANY OF THE FOLLOWING CONDITIONS?HYPERTENSION? Yes No DIABETES? Yes No IF SO, ARE YOU INSULIN DEPENDENT? HEART DISEASE? Yes No IF SO, ARE YOU TAKING MEDICINE? SEIZURES? Yes No IF SO, ARE YOU TAKING MEDICATION? ASTHMA Yes No ALLERGIES (FOODS, PLANTS, INSECTS, MEDICATIONS ETC.). IF SO, PLEASE DESCRIBE:HAVE YOU HAD A RECENT CONCUSSION? DO YOU WEAR CONTACT LENSES? DO YOU KNOW THE DATE OF YOUR LAST TETANUS SHOT? PLEASE LIST ANY PERTINENT MEDICAL HISTORY OR MEDICATION YOU ARE TAKING:PERSON TO CONTACT IN THE CASE OF AN EMERGENCY(Required) First Last PHONE NUMBER(Required)
