VHF Guardian & Staff Medical Form

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:

(Eg M72, M73, M74)

Select 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.

Please list all medications (including over the counter)

Rows	Medication Name	Dose	Time Taken	Reason for Taking
1.
2.
3.
4.
5.
6.
7.

Are there more medications to list?

Please list all medications (including over the counter)

Rows	Medication Name	Dose	Time Taken	Reason for Taking
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Are there any more medications to list?

Please list all medications (including over the counter)

Rows	Medication Name	Dose	Time Taken	Reason for Taking
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

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?

Is an epi-pen needed for allergic reaction?

List all 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.

The next items are a requirement for all volunteers.

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?

Can you walk at least 2 miles on uneven surfaces wearing a backpack while pushing a Veteran in a wheelchair who weights up to 250lbs?

Are you able to bend, squat, or kneel multiple times throughout the day?

Are you able to climb 6 bus steps multiple times during the day?

Are you able to remain alert and prepared to assist your veteran should he/she require it for the duration of the mission, approximately 24 hours?

Please complete the remaining general medical questions below.

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.

Do you have experience as a caregiver, either professionally or personally?

Please explain.

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):

Emergency Hospital Use: May release updated medical information to the following people:

Rows	First Name	Last Name	City	State	Cell Phone Number	Relation
1.
2.

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.

Guardian & Staff Medical Form

Please Note: Emergency Contacts listed below CAN NOT BE ON THE FLIGHT.