Health History and Emergency contact information
safety is high priority in all programs. we strongly recommend that you consult your health care provider if you are pregnant or have any medical or emotional conditions that may affect your ability to participate safely.
certain health information may be important for out guides to know during your climbing program with twin cities rock and ice llc. all information on the following forms will be kept confidential and it will be seen only by staff, medical personnel, or other who know and understand its confidential nature.
Participant
Name *
Name
Today's Date
Today's Date
Date of Birth *
Date of Birth
Sex
Emergency contact
In case of emergency, please contact
Name
Name
Primary Phone *
Primary Phone
Secondary Phone
Secondary Phone
Health History
do you currently have or have you had a history of:
Hypertension
Heart attach or heart disease
Heart palpitations or murmur
Chest pain / pressure
Stroke
Smoking
Diabetes
Respiratory problems
Gastrointestinal concerns
Genitourinary concerns
Bleeding or blood disorders
Infectious diseases
Neurologic problems, seizures
Dizziness or fainting
Mental Health concerns
Recent illness
Joint or extremity pain / injury
Spine pain or injury
Dietary restrictions
Eating disorders
Frostbite or cold injury
Heat injury
Altitude illness
Major surgery
Physical disability
Allergies (insects, food, drugs, etc.)
Are you currently under the care of a medical professional?
Are you pregnant?
Any other health concerns?
Do you wear contacts?
Are you currently using or carrying any medication?
Declaration and Consent
To the best of my knowledge, the above information is a complete and accurate representation of my pertinent medical history. I declare that I am in good physical health and believe that I am able without reservation or limiting conditions to physically withstand and cope with the indicated rigors of this program. In the event of an emergency, permission is given for any evacuation, medical intervention and care that may become necessary for my immediate well being.
Electronic Signature Consent *
Electronic Signature *
Electronic Signature
Date *
Date