User Guide

Page 4 of 5 Imperial Physicker's Manual

as adopted August 1992, amended December 1998

PPENDIX

B: M

EDICAL

NFORMATION

ORM

This form is intended to gather voluntary medical information for members of the Adrian Empire, Inc. to aid

emergency medical personnel if ever a need arises.

Mundane name: _________________________ Persona:_____________________________________

Home phone number: _____________________ Cell phone number:____________________________

Address: ____________________________________________________________________________

Emergency contact and number: _________________________________________________________

Allergies: ___________________________________________________________________________

Medications: _________________________________________________________________________

Any history of the following:

Hypertension ! Yes ! No Heart disease ! Yes ! No

Diabetes ! Yes ! No Asthma ! Yes ! No

Seizures ! Yes ! No Glasses/contacts ! Yes ! No

Excessive bleeding or clotting problems ! Yes ! No

Additional information (especially if answered yes to any of the above questions) __________________

___________________________________________________________________________________

Chartered Subdivision:____________________ Physiker:_____________________________________

I, the undersigned, do acknowledge that the information I have given on this form is purely voluntary, and that

I have the authority to issue it.

___________________________________________________________________________________

Signature (parent or legal guardian must sign if the named person is a minor.) Date