Medical Questionnaire is a requirement to participate in the WOW program (Mail or Scan)
Name________________________________________________ Date of Birth _________________ Sex _______
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
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
4.Have you ever been told by a doctor you have epilepsy? NO YES
5.Have you ever been treated for diabetes? NO YES
6.Have you ever had a serious accident? NO YES
7.Do you have a history of high blood pressure? NO YES
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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