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Confidential Medical Information

A Medical information form is required of all people joining any expedition.  You can either download the form and send via the mail, or fill out the online form below.

Download the form

FHE Medical History Form – Please download, fill out, and send the form back to:

Garrett Cooper
10516 Bastille Ln. 
Apt 203
Orlando Fl 32836

Online Submission

Fill the form out below:

* = required

Name*:
Address*:
City*:

State*:

Zip*:

Home Phone*:
Cell Phone:
Email Address:

Date of Birth*:

Do you have allergic reactions to any food, drugs, insects, plants, or other substances? YesNo

Describe your allergy/allergies:
Do you carry an Epi-Pen, auto injector, medications, or devices?
If no allergies exist, initial here:

Are you presently under the care of a physician?

Please list and explain any medical conditions:

Physician’s Name:

Physician’s Phone:

Are you presently taking any prescription medications?

If no medical conditions exist, initial here:
What type and for what?

In Case of Emergency, Notify:

Contact's Name:

Contact’s Phone:

Contact’s relationship to you: