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?

    [group allergy-group-yes]
    Describe your allergy/allergies:
    Do you carry an Epi-Pen, auto injector, medications, or devices?
    [/group]

    [group allergy-group-no]
    If no allergies exist, initial here:


    [/group]

    Are you presently under the care of a physician?

    [group physicians-group-yes]
    Please list and explain any medical conditions

    Physician’s Name

    Physician’s Phone:
    [/group]

    [group physicians-group-no]
    If no medical conditions exist, initial here:


    [/group]

    Are you presently taking any prescription medications?

    [group prescription-group-yes]
    What type and for what?
    [/group]

    In Case of Emergency, Notify:

    Contact's Name

    Contact’s Phone

    Contact’s relationship to you