Survival and Tactical Systems LLC 376 Rose Bud Ln Holly Ridge

 Survival and Tactical Systems LLC 376 Rose Bud Ln Holly Ridge NC 28445 History/Health Information
Name: _______________________________________
Birth Date: _______________________
Today’s Date:_________________
Address: _____________________________________
Phone Number:____________________
Email Address:________________________________
Name of person to call in case of emergency: ___________________________
Phone Number of emergency contact:______________
Family Medical Doctor: _________________________
Your Blood Type: _________________
Medical History
Have you ever been diagnosed as having or suffered from any of the following?
__ Circulatory Problems
__ Epilepsy
__ Shortness of breath
__ Seizures/Convulsions
__ Pace Maker
__ Chronic Bronchitis
__ a Congenital Disease
__ Strokes
__ Diabetes
__ Excessive Bleeding
__ Hypertension
__ Heart Arrhythmia
__ High/Low Blood Pressure
__ Asthma
__ Difficulty Hearing
List any other heath conditions or concerns that you have/are being treated for:
What medications do you currently take? Please include supplements.
Do you currently take fish oil? __ Yes __No
If yes, how many milligrams a day? __________________________
Do you have any known allergies to any medications? __ Yes __ No
If yes, please describe:
Social History:
Do you smoke? __ Yes __ No
If yes, how many packs a week? _______________
Do you consume Coffee? __ Yes __ No
If yes, how much per day? ____________________
Do you drink alcoholic beverages? __ Yes __ No
If yes, how much per week? ___________________
The information that you have provided helps Survival and Tactical Systems, LLC get you the medical care that you
may need in case of emergency. Your medical information is for Survival and Tactical Systems, LLC ’s records
only. Your medical information will not be shared with anyone (doctors, insurance companies, or employers) for
any reason other than an emergency to better care for you.
Participants Signature: ___________________________________________