Med Forms Expeditioncrew No or staff position Checking this box indicates you DO NOT want your child to use a BB device Checking this box indicates you DO NOT want your child to use a BB device None None List participant restrictions if any Date Date_2 Name Phone Name_2 Phone_2 Name_3 Phone_3 Name_4 Phone_4 Expeditioncrew No_2 or staff position_2 Age Gender Height inches Weight lbs Address City State ZIP code Phone_5 Unit leader Unit leaders mobile Council NameNo Unit No HealthAccident Insurance Company Policy No Name_5 Relationship Address_2 Home phone Other phone Alternate contact name Alternates phone Last HbA1c percentage and date Insulin pump Yes NoHypertension high blood pressure Last HbA1c percentage and date Insulin pump Yes NoAdult or congenital heart diseaseheart attackchest pain angina heart murmurcoronary artery disease Any heart surgery or procedure Explain all yes answers Last HbA1c percentage and date Insulin pump Yes NoFamily history of heart disease or any sudden heartrelated death of a family member before age 50 Last HbA1c percentage and date Insulin pump Yes NoStrokeTIA Last attack dateLungrespiratory disease Last attack dateCOPD Last attack dateEareyesnosesinus problems Last attack dateMuscularskeletal conditionmuscle or bone issues Last attack dateHead injuryconcussionTBI Last attack dateAltitude sickness Last attack datePsychiatricpsychological or emotional difficulties Last attack dateNeurologicalbehavioral disorders Last attack dateBlood disorderssickle cell disease Last attack dateFainting spells and dizziness Last attack dateKidney disease Last seizure dateAbdominalstomachdigestive problems Last seizure dateThyroid disease Last seizure dateSkin issues CPAP Yes No Last surgery dateList any other medical conditions not covered above Expeditioncrew No_3 or staff position_3 AUTOINJECTOR Exp date if yes INHALER Exp date if yes Medication ExplainPlants Food ExplainInsect bitesstings Check here if no medications are routinely taken Check here if no medications are routinely taken MedicationRow1 DoseRow1 FrequencyRow1 ReasonRow1 MedicationRow2 DoseRow2 FrequencyRow2 ReasonRow2 MedicationRow3 DoseRow3 FrequencyRow3 ReasonRow3 MedicationRow4 DoseRow4 FrequencyRow4 ReasonRow4 MedicationRow5 DoseRow5 FrequencyRow5 ReasonRow5 MedicationRow6 DoseRow6 Nonprescription medication administration is authorized with these exceptions FrequencyRow6 ReasonRow6 Tetanus Pertussis Diphtheria medical history 1 medical history 2 medical history 3 medical history 4 Measlesmumpsrubella Polio Chicken Pox Reviewed by Hepatitis A Date_3 Hepatitis B Meningitis Reason Influenza Approved by Other ie HIB Date_4 Exemption to immunizations form required Last Attack Date Last Seizure Date Last surgery date Diabetes YesNo Hypertension YesNo Adult or congenital heart disease YesNo Family history of heart disease YesNo Stroke TIA YesNo Asthma YesNo Lung respiratory disease YesNo COPD YesNo Ear eyes nose sinus problems YesNo Muscular skeletal condition muscle or bone issues YesNo Head injury concussion YesNo Altitude sickness YesNo Psychiatric psychological or emotional difficulties YesNo Behavioral neurological disorders YesNo Blood disorders Sickle cell disease YesNo Fainting spells and dizziness YesNo Kidney disease YesNo Seizures YesNo Abdominal stomach digestive problems YesNo Thyroid disease YesNo Excessive fatigue YesNo Obstructive sleep apnea sleep disorders YesNo List all surgeries and hospitalizations YesNo List any other medical conditions not covered above YesNo MEDICATION NO Choice3Choice4 If additional space is needed please list on a separate sheet and attach If additional space is needed please list on a separate sheet and attach Text6 Text7 Text8 Text9 Text10 Text11 Text12 Text13 Text14 Text15 Text16 Text17 cpap cpap yescpap no Epinepherine YesNo Asthma Rescue YesNo Medication Allergies YesNo Food Allergies YesNo Plant Allergies YesNo Insect Bites YesNo Non prescription med admin YesNo Tetanus Shot YesNo Pertussis Shot YesNo Diptheria Shot YesNo Measles Shot YesNo Polio Shot YesNo Chicken Pox Shot YesNo Hepatitis A Shot YesNo Hepatitis B Shot YesNo Meningitis Shot YesNo Flu Shot YesNo Other Shot YesNo Exepmtion Shot YesNo Further Approval Require YesNo Last HbA1c Full name Date of birth Your name Your email Subject Your message (optional)