Mt. Morris Camp and Conference Center

MEDICAL DISCLOSURE/HEALTH FORM

We require that this form be filled out in full.

Name: ____________________________________________________________

Address: __________________________________________________________

__________________________________________________________________

Phone: ____________________________________________________________

Age: _________

In case of emergency please notify:

Name: ____________________________________________________________

Phone: ____________________________________________________________

Relationship: _______________________________________________________

Physician Name: ____________________________________________________

Physician Phone: ____________________________________________________

Medical Policy and Number: ___________________________________________

1. Do you smoke? Number of packs per day_____	__YES __NO
2. Do you wear glasses or contacts:	__YES __NO
3. Are you currently under a physicians care?	__YES __NO
If yes please explain:_____________________________
4. Are you currently taking medication?	__YES __NO
If yes please explain:_____________________________
5. Do you have any allergies?	__YES __NO
If yes please explain:_____________________________
6. Do you require special assistance of any type?	__YES __NO
If yes please explain:_____________________________
7. Have you had a recent injury, illness, or operation?	__YES __NO
If yes please explain:_____________________________
8. Do you have diabetes, seizures, or frequent fainting/dizziness?	__YES __NO
If yes please explain:_____________________________
9. Do you have neck, back or shoulder pain or injury:	__YES __NO
Please explain: __________________________________
10. Does your weight present health problems or limit physical activities?	__YES __NO
Please explain: __________________________________
11. Do you have a history of heart problems or high blood pressure?	__YES __NO
Please explain: __________________________________
If you have checked yes to #11 please note the information on the Following page.

Participant’s Signature: ____________________________________ Date: ____________