Date of Birth *

MM

DD

YYYY

Nutritional requirements

Do you have specific food or nutritional requirements?

Vegetarian

Gluten free

Lactose intolerant

OTHER

Do you have or have you had any of the following conditions?

Epilepsy/seizures

Bleeding/clotting disorder

Heart attack

Heart disease

Heart murmur

Stroke

Asthma

Emphysema

High blood pressure

Diabetes

Hypoglycemia

Lung disease

Seizures of any kind

OTHERS we should know about

None

Allergic reactions

Do you have known allergic reactions to any of the following?

Environmental substances

Foods

Drugs

Sensitivity to insects

Sensitivity to stings / anaphylactic shock

Do you have any of the following disabilities?

Back

Knees

Hips

Ankles

OTHER

When walking

If you walked on the level for a mile at an average pace, would you:

Get out of breath

Have chest pain

Have leg pain

Develop muscle fatigue

OTHER

Are you taking any prescribed medications at this time?

Yes

No

Physical fitness

Excellent

Good

Average

Fair

Poor

Treatment *

Are you currently (or within the pat two years) receiving treatment from a physician or other health care professional for any physical or psychological reason?

Yes

No

Have you ever been told that your SNORING is serious enough that it can disturb others?

Yes

No

Check here if you need an electrical outlet for a breathing a CPAP or other breathing device.

Will you have any special medical requirements during the MROP?

Yes

No

Today's Date *

MM

DD

YYYY

Medical release *

By checking this box, I authorize the ILLUMAN DC staff to provide this information to medical professionals providing me emergency care during this event.

Yes, I authorize ILLUMAN DC to release this medical information