Health Information Form
WALKING THE WORLD®
HEALTH INFORMATION (Please print or type and attach additional explanation where necessary.)
TRIP APPLIED FOR: _______________________________________________________________________ NAME____________________________________________________________________________________
ADDRESS________________________________________________________________________________ CITY/STATE/ZIP________________________________________Ph# ( )__________________________ AGE______ BIRTHDATE__________ SEX______ HEIGHT____________ WEIGHT___________
GENERAL STATEMENT OF HEALTH__________________________________________________________
_________________________________________________________________________________________
MEDICAL OR DIETARY RESTRICTIONS_______________________________________________________
_________________________________________________________________________________________
ALLERGIES (medications, foods, animals or insects, etc.)________________________________________
_________________________________________________________________________________________
MEDICATIONS YOU ARE TAKING NOW (Please list the reasons as well.)____________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
EMERGENCY INFORMATION (Whom to contact in case of emergency):
NAME___________________________________________ RELATIONSHIP__________________________
ADDRESS_________________________________________________________________________________
CITY/STATE/ZIP____________________________________________________________________________ HOME PHONE_____________________________ WORK PHONE_________________________________
(AREA CODE + NUMBER) (AREA CODE + NUMBER)
PRIMARY CARE PHYSICIAN:
NAME_____________________________________________________________________________________ ADDRESS__________________________________________________________________________________
CITY/STATE/ZIP_____________________________________________________________________________ PHONE (AREA CODE + NUMBER)______________________________________________________________ Please return this form to:
Walking The World®, P.O. Box 1186 Fort Collins, CO 80522-1186
PH: 970-498-0500 Email: info@walkingtheworld.com Website: www.walkingtheworld.com |
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