Guardian Medical Form

Guardian Medical Form

Villages Honor Flight
Date:*

MonthDayYear
MM/DD/YYYY
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:*
Guardian's Name as it appears on Photo ID (for TSA purposes):*

First NameMiddle NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*

Area CodePhone Number
Other Phone Number

Area CodePhone Number
Email*
example@example.com
Are you vaccinated for COVID?
Date of first shot:

MonthDayYear
Date
Date of second shot:

MonthDayYear
Date
Date of Booster shot:

MonthDayYear
This is NOT a Required Field.
Date of Birth*

MonthDayYear
Date
Weight*
(lbs)
Height*
Can you walk up bus steps carrying Veteran's items, if needed?*
Please explain limitations or concerns. *
You may add as much information as needed the field will expand.
Can you walk at least 2 miles on uneven surfaces, pushing a Veteran in a wheelchair? *
Please explain limitations or concerns. *
You may add as much information as needed the field will expand.
Have you fallen in the past 6 months? *
Did you trip? Lose your balance? Feel faint or dizzy? Other? Explain answer.*
You may add as much information as needed the field will expand.
Have you had an MRI, CT scan, X-Ray in the past 6 months? *
Why? Explain answer.*
You may add as much information as needed the field will expand.
Have you had any recent surgery? *
What type of surgery?*
You may add as much information as needed the field will expand.
Do you have problems with motion sickness?*
Is it controlled by medication? Explain answer.*
You may add as much information as needed the field will expand.
Do you have any heart conditions? Palpitations? Angina? Atrial Fibrillation? *
List conditions, meds, blood thinner, etc. Explain answer.*
You may add as much information as needed the field will expand.
Do you have a pacemaker/internal defibrillator?*
Explain answer including blood thinner taken and last time it was checked.*
You may add as much information as needed the field will expand.
Do you have any food allergies?*
List food allergies. Explain answer.*
You may add as much information as needed the field will expand.
Do you have any special dietary needs?*
List special dietary needs. Explain answer.*
You may add as much information as needed the field will expand.
Do you take any medications?*
List medications.*
You may add as much information as needed the field will expand.
Do you have any medication allergies?*
List medication allergies. Explain answer.*
You may add as much information as needed the field will expand.
Are you a diabetic?*
What medications do you use.*
You may add as much information as needed the field will expand.
Guardian

MD Rx or photo of insulin Rx needed for flight.
Do you self administer your insulin or does someone else give you the shot? Does your insulin require refrigeration?*
You may add as much information as needed the field will expand.
Do you have any environmental allergies?*
List environmental allergies. Explain answer.*
You may add as much information as needed the field will expand.
Have you been told, or do you believe you have PTSD?*
Explain answer.*
You may add as much information as needed the field will expand.
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:*
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*

MonthDayYear
Date
PRINT FORM if you desire then Click On SUBMIT.
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