PUERTO RICO MISSION TRIP

Health & Emergency Questionnaire

Full Legal Name

As it appears on your drivers license or insurance card.

First Name

Last Name

Email Address

Phone

(###)

###

####

EMERGENCY CONTACT INFORMATION

Name 1

Relationship 1

Phone 1

(###)

###

####

Name 2

Relationship 2

Phone 2

(###)

###

####

MEDICAL INSURANCE INFORMATION

Insurance Company

Group / Policy Number

Plan ID#

Insurance Comments

If you have additional numbers/prescription plans or other key information you think we should have.

HEALTH INFORMATION

List any allergies you may have

Food, medicine, environmental, insects, etc.

Check all that apply

Diabetes

Asthma

Heart Condition

Epilepsy / Fainting

High Blood Pressure

Physical Disability

Psychiatric / Emotional Condition

Explain chronic or current health conditions

Current medications (include name, dosage/strength and condition it treats)

Date of Last Tetanus Shot (if known)

OTHER INFORMATION

Additional comments or information you would want relayed to health professionals if you are unable to.

Health & Emergency Questionnaire

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