New England Regional Ski For Light

PERSONAL HEALTH HISTORY

     MEDICAL INSURANCE IS NOT PROVIDED FOR PARTICIPANTS. YOU ARE
     RESPONSIBLE FOR ACCIDENT/ILLNESS COSTS INCURRED DURING THE
     PROGRAM.

Name:                                             Date: 
Are you covered by any health/medical insurance? (Y/N):
Name of health insurance Co.:                          Policy #: 
Address:
City, State, Zip:                                     Phone: (   ) 
Does your insurance company require pre-authorization prior to treatment? (Y/N):
Have you had any chronic or serious illnesses? (Y/N):
If "YES" explain:

Do you have any medicine or food allergies? (Y/N):
If "YES" please explain 

Please list any medication you take. Include the name, dosage,
dosage schedule and the reason you take the medication (e.g.
Hydrochlorothiazide 50 mg twice a day for high blood pressure):


Please indicate if you have a history of:

pneumonia (Y/N):            
epilepsy (Y/N):
bronchitis  (Y/N):
frequent headaches (Y/N):
asthma (Y/N):
fainting/dizziness (Y/N):
emphysema (Y/N):
bursitis/tendinitis (Y/N):
high blood pressure (Y/N):
arthritis (Y/N):
angina (Y/N):
back pain  (Y/N):
rapid/irregular pulse (Y/N):
balance problems  (Y/N):
chest pain  (Y/N):
hypoglycemia (Y/N):
shortness of breath (Y/N):
depression/anxiety (Y/N):
circulation problems (Y/N):
diabetes (Y/N):
stroke (Y/N):
hearing impairment (Y/N):
altitude sickness (Y/N):
mobility impairment (Y/N):
motion sickness (Y/N):
other medical problems (Y/N):

If you answered "YES" to any of the above questions please explain:



ADDITIONAL QUESTIONS:

What is your current level of activity?--
Fairly sedentary (walk less then one block/day, no formal exercise) (Y/N):
Limited activity (walk 1-6 blocks daily, aerobic-exercise less than 3 times/week) (Y/N):
Moderately active (aerobic activity 4-7 times/week, organized fitness) (Y/N):
Very active (distance running/biking/skiing/swimming, etc. daily) (Y/N):

THE ABOVE INFORMATION AND PERSONAL HEALTH HISTORY IS ACCURATE
TO THE BEST OF MY KNOWLEDGE.

Signature: ______________________  Date: