Survival and Tactical Systems LLC 376 Rose Bud Ln Holly Ridge NC 28445 survivaltacticalsystems.com History/Health Information Name: _______________________________________ Birth Date: _______________________ Today’s Date:_________________ Address: _____________________________________ Phone Number:____________________ Email Address:________________________________ Occupation:_______________________ Name of person to call in case of emergency: ___________________________ Phone Number of emergency contact:______________ Relationship______________________ 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: ___________________________________________