MEDICAL INFORMATION FORM

 

Name:	Student ID#:	Address:
City:	State:	Zip:
Home Phone:	Age:	Birthdate:
Social Security#:	Height:	Weight:

In case of emergency, please contact:

Name:	Relation:	Address:
City:	State:	Zip:
Work Phone:	Home Phone:	Cell Phone:
Place of Work:	Business Phone:
Doctor's Name:	Doctor's Phone:

      
                                                                                              

Are you covered by medical insurance?	Yes	No
Are you currently under a Physician's orders for medication or treatment?	Yes	No
Will you have these medications with you on any outing?	Yes	No
Are you allergic to insect stings, poison ivy, foods, drugs, or other things?	Yes	No

Please check any of the following conditions that pertain to you:

 

Diet or Eating Disorder	Past Injuries / Illnesses	Neck / Back Problems
Respiratory Condition	Fractures	Diabetes
Asthma	Epilepsy / Convulsions	Past Operations
Physical Disabilities	Digestive/ acid reflux	Other

If you answered yes to any of the above questions or checked a condition from the above list, please list the medications, dosage, and the frequency with which these are taken; describe specific allergies, your symptoms, the frequency of occurrence, how you care for the condition and how this condition restricts your activity in any way; and/or describe all information, including specific symptoms, how long the symptom/condition lasts, frequency of occurrence, how you care for symptom/condition, and how the condition restricts your activity in any way.

Authorization for Emergency Medical Care: Should an accident occur, I hereby give permission to the physician selected by The University of Tulsa Get Outside Staff to hospitalize and/or secure proper medical treatment for me except as noted below. I agree to hold only myself liable for these noted exceptions.

Signature:(Please Type Full Name)	Date:
Last Name:	First Name:
Signature of Parent or Gaurdian (if under 18 years old):