Volunteer Health Information Form
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4WEST CENTRAL OHIO MEDICAL RESERVE CORPS
VOLUNTEER HEALTH INFORMATION FORM
Please print clearly.
Today’s date
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Title: Dr. Mrs. Mr. Ms.
Last Name
__ First Name
Middle
_____
Describe any restrictions/limitations you have on activities:
________________________________________________________________________________
_____________________________________
_____________________________________
List all medications, vitamins, herbs and over the counter drugs you usually take: _______________
__________________________________________________________
_____________________________________
Please list any allergies or other medical conditions that a physician would need to be aware of:
_
__________
___________________________________________________________________________
Please circle any vaccines you have received below :
Anthrax #1 #2 #3 #4 #5 #6 Booster (date) _________
Polio
MMR #1
#2
Smallpox (date) ___________
Hepatitis A
#1
#2
Tetanus (date)
_
Hepatitis B series #1
#2
#3
Typhoid (date) ___________
Influenza (date)
__
Meningococcal (date) __________
Yellow Fever (date):
____Tb skin test (date):
Emergency Contact : ____________________________Telephone number: ___________________
may we call your emergency contact person in the event of an emergency?
Yes
No
Please return this form to:
Sandy Miller, RN
Clark County MRC Coordinator
529 E. Home Road
Springfield, Oh 45503
(937) 390-5600 ext 262
Fax (937) 390-5625
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