VHF Guardian & Staff Medical Form

Date*

Date

Your safety on this mission is our first and most important concern.

Please answer the questions to the best of your ability.

"All items marked * are Required."

Enter Mission Number:*

Name as it appears on photo ID (for TSA purposes)*

First NameMiddle NameLast NameSuffix

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Cell Phone Number*

Area CodePhone Number

Other Phone Number

Area CodePhone Number

Email Address*

example@example.com

Date of Birth:*

MM/DD/YYYY

Weight*

(lbs)

Height*

Please list all medications (including over the counter), including dose, time taken and REASON FOR TAKING. Reminder all medicine, ie. eye drops, insulin, must be self administered.*

Do you have any medication allergies?*

List medication allergies and reaction.*

You may add as much information as needed the field will expand.

Do you have any environmental allergies? Bee stings?*

List allergies and reactions.*

Do you have any food allergies?*

List food allergies and reaction.*

You may add as much information as needed the field will expand.

Do you have any special dietary needs?*

List special dietary needs.*

Can you walk at least 2 miles on uneven surfaces, pushing a Veteran in a wheelchair?*

Can you adhere to the policy of no tobacco/smoking/vaping/chewing for 24-hours on mission day?*

Can you adhere to the policy of no consumption of alcohol for 24-hours on mission day?*

This is a requirement for all volunteers.

Have you fallen in the past 6 months? *

Did you trip? Lose your balance? Feel faint or dizzy? Other? Explain answer.*

Do you have a history of seizures?*

What type? When was your last seizure? Explain answer.*

Have you been diagnosed by a physician or do you believe you have PTSD? Anxiety?*

Explain answer, including triggers and how we may help you.*

Do you have any heart conditions? Palpitations? Angina? Atrial Fibrillation?*

List conditions. Explain answer.*

Do you have a pacemaker/internal defibrillator?*

When was pacemaker last interrogated? Explain answer.*

Do you have breathing problems such as Asthma? COPD? Emphysema? Shortness of breath on exertion?*

List problems. Explain answer.*

Do you have diabetes?*

Do you self administer your insulin or does someone else give you the shot? Does your insulin require refrigeration?*

Do you have motion sickness when flying?*

How do you treat? Explain answer.*

Are there any other health issues or problems that weren’t discussed that we should know about for your safety on the mission?*

Explain answer.*

You may add as much information as needed the field will expand.

Emergency Hospital Use: May release updated medical information to the following people (include name and phone number):*

I hereby authorize Villages Honor Flight, its officers, employees, members, participants, users and/or volunteers, to take the action they believe is appropriate in an emergency situation. Further, I agree to indemnify and hold harmless Villages Honor Flight organization, any officer, employee, member, participant, user and/or volunteer thereof, against any claim(s) arising out of said emergency care.

Typing your name below constitutes your digital signature when sending via email.

Signature*

Today's Date*

Date

PRINT FORM if you desire then Click On SUBMIT.