Confidential Medical Information - Feral Human Expeditions

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:

Medical Information Form

Name

Address

City

State/Province

Zip/Postal

Country

Home Phone

Cell Phone

Date of Birth

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

Yes

Allergy: Yes

Describe your allergy/allergies:

Do you carry an Epi-Pen, auto injector, medications, or devices?

Allergy: No

If no allergies exist, initial here

Clear

Are you presently under the care of a physician?

Yes

Physician: Yes

Please list and explain any medical conditions

Physician's Name

Physician’s Phone

Physician: No

If no medical conditions exist, initial here

Clear

Are you presently taking any prescription medications?

Yes

Prescriptions: Yes

What type and for what?

Please list any additional conditions or concerns you’d like to let us know about:

In Case of Emergency, Notify:

Contact's Name

Contact’s Phone

Contact’s relationship to you

If you are human, leave this field blank.