Medical Questionnaire is a requirement to participate in the WOW program (Mail or Scan)
 
Name________________________________________________   Date of Birth _________________  Sex _______
Street Address___________________________________________________________________________________
City/State/Zip___________________________________________   Phone (_______) _________________________
Medical Ins. Co. _________________________________________________________________________________
Policy No.____________________________________   Group No. ________________________________________
Emergency Contact________________________________________   (Relationship) __________________________
Phone (_______) ____________________________________
Primary Physician_________________________________________   Phone (_______) _______________________
 
ALL INFORMATION WILL BE CONFIDENTIAL. Please circle “Yes” or “No” and provide additional details where required.
1. Are you allergic to any medications?     NO      YES
LIST
 
2. Are you currently taking any medications on a regular basis?      NO      YES
Please List with Reason
 
3.Have you ever had a seizure?      NO      YES
WHEN
 
4.Have you ever been told by a doctor you have epilepsy?      NO     YES
WHEN
 
5.Have you ever been treated for diabetes?      NO      YES
WHEN
 
6.Have you ever had a serious accident?      NO      YES
WHEN
 
7.Do you have a history of high blood pressure?      NO       YES
WHEN
 
8.Do you have or have you ever had the following diseases:
 
Hay fever                        NO       YES       WHEN                        Heart disease        NO       YES        WHEN
Fainting spells                 NO       YES       WHEN                        Lung disease        NO       YES         WHEN
Frequent diarrhea           NO       YES       WHEN                        Kidney disease      NO       YES        WHEN
Severe stomach aches   NO       YES       WHEN                        Liver disease         NO       YES        WHEN
Menstrual problems        NO       YES       WHEN                        Hepatitis                NO       YES        WHEN
Ear ache or infection      NO        YES       WHEN
 
9.Have you ever been told by a doctor that you have asthma?      NO       YES       WHEN
 
10.Have you ever had a concussion or head injury?      NO        YES        WHEN
 
11.Are you pregnant?       NO        YES       DUE DATE
 
12.Have you stayed overnight in a hospital?   WHY? ____________________________________________________
13.Date of last tetanus inoculation _________________________________exact date needed (must be within 10 years)
 
The above medical history questionnaire is correct to the best of my knowledge, and I am able to engage in all activities, except as noted by a physician and me. In the event of an emergency, I hereby give permission to a physician to hospitalize me, secure proper anesthesia, and to order injections, x-rays, surgery or other medical procedures required by the emergency situation.
 
By signing this form, you are giving consent for the North Carolina Wildlife Resources Commission to provide this information to emergency personnel in a medical emergency situation.
 
 
Signature of Participant____________________________________________________   Date___________________

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