Information and Medical History Form

(Please type or print legibly in black ink)

Section 1: General

Name: / Today’s Date:
Name of Course: / Date of Course:
What do you hope to gain from this course?
Address:
City / State / Zip:
Home Phone #:
Mobile Phone #: / E-mail:
Height: / Weight: / Date of Birth: / Age:

Section 2: Experience

Describe your swimming ability: / What was the last CWA beginner trip/class you were on?
How is your pool roll?
1=none
10 = highly reliable / How is your combat roll?
1=none
10 = highly reliable

Section 3: Medical Information & History

Have you ever had? (Please check the Yes or No column.)

Condition / Yes / No / Condition / Yes / No
Diabetes / Back Problems
Heart Disease / Asthma
High Blood Pressure / Are you greatly affected by heat
Dislocations / Shoulder Problems / Are you pregnant
Do you get cold easily / Wear glasses or contacts
Surgery
If you answered Yes to any of the above items, please explain:
Are you taking medication? If so, what?
Any side effects of medication such as sun sensitivity, fatigue, etc.?

Section 3: Medical Information & History (cont’d.)

Do you have muscle spasms? If Yes, what triggers them?
Do you have a history of seizures? If so, what triggers them and when was your last seizure?
Are you allergic to anything (medications, food, latex, insect stings, etc.)? If so, what?
If you are allergic to insect stings, do you carry any medication? / Do you want the instructor to administer that medication to you if you are stung and do you agree to hold that instructor harmless for doing so? (Realize this is waiving some legal rights you may have.) / Initial / Date
Do you have a disability? If yes, please describe:
How long have you had the disability?
Do you have a mobility impairment? If yes, please describe:
Do you have a sensory impairment (sight, sounds or sensation)? If yes, please describe:
So that we can better understand your needs, please list any medical, physical, psychological or emotional issues not mentioned above

Section 4: Emergency Information

Insurance Company Name and Phone #: / Group / ID #:
Physician’s Name and Phone #:
Emergency Contact:
Phone #:
Relationship

The above information is true.

Participant’s Signature:______