Download — Logistical Information and Packing List Wandering Into Wellness CONFIDENTIAL HEALTH QUESTIONNAIRE Note: The information in this form is collected for informational, safety purposes and gives permission to the Verdant Collective guides on this trip to seek emergency medical diagnosis or treatment for you in the event that you are unconscious or unable to make your own decisions. Today's Date * MM DD YYYY Name * First Name Last Name Birth Date * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone Number * (###) ### #### FOR EMERGENCY USE Your Doctor's Name * First Name Last Name Your Doctor's Phone Number * (###) ### #### Medical Insurance Company * Group/Policy Number * Emergency Contact * First Name Last Name Emergency Contact Phone Number * (###) ### #### Emergency Contact's Relationship to You * Do you wear a Medic-Alert Tag or any other marker of a medical condition? If yes, please describe Have you ever had a heart attack of any kind, or been told by a doctor that you have high blood pressure, a heart murmur or heart disease? If yes, please describe Have you ever experienced a seizure of any kind? If yes, please describe Do you have a lung disease or any kind of breathing condition? If yes, please describe Do you have any other chronic disease that, in any way, threatens your health? If yes, please describe Do you have allergic or anaphylactic reactions to anything, such as environmental substances, foods, drugs, insect bites or stings? If yes, please describe Do you have hemophilia or any other disorder that impairs blood-clotting? If yes, please describe Do you have hypoglycemia or diabetes? If yes, please describe Are you taking any medication at the present time? If yes, specify each drug, the dose and the reason for taking Any dietary preferences or needs? If yes, please describe Agreement * This information is accurate and complete. I agree to cooperate with the retreat facilitators to design an outdoor experience with full consideration of my health history and health concerns. I give my permission to The Verdant Collective guides on this trip to seek emergency medical diagnosis or treatment for me in the event that I am unconscious or unable to make my own decisions. The Verdant Collective guides' role in offering medical treatment will be limited to emergency first-aid and either transportation to the nearest medical facility, or contacting such a facility to arrange emergency transport. Thank you!
