About CCH + Documents: Medical Form
Emergency Contact Information
Legal Name (as appears on your passport)______________________________
Home Phone __________________________
________________________________________________________________________
Emergency Contact
Name: _____________________________
Home Phone: _______________________-_
Work Phone: ________________________
Alternate Emergency Contact
Name: _____________________________
Home Phone: _______________________-_
Work Phone: ________________________
Physician
Primary Care Physician: __________________________________
Phone: _______________________________________________
Address: ______________________________________________
Medical Information
Current Medications (include medications for emergency use such as Epi-pen):
________________________________________________________________________
Medical Conditions (e.g. Asthma, Diabetes): ________________________________________
________________________________________________________________________
Recent Surgery or Serious Injury: ________________________________________________________________________
________________________________________________________________________
Drug Allergies: ________________________________________________________________________
________________________________________________________________________
Other Allergies (e.g. Bee Stings, Foods, Hay fever): ________________________________________________________________________
________________________________________________________________________
Date of last Tetanus Booster: ________________________________________________________________________