Medical Information Form - Vietnam 2018
Please complete this form in its entirety. All information will be kept in strictest confidence and will be available only to PhotoEnrichment Adventures personnel on a need-to-know basis, as well as to necessary authorities in the case of an emergency.

We strongly recommend that you contact your personal physician for recommendations regarding your individual health requirements while traveling. You should also be up-to-date with all of your shots, including tetanus and standard immunizations.

If you haven't already, please start thinking about updating any of your vaccinations that may be out of date (check with your doctor) and see the Centers for Disease Control website (http://wwwnc.cdc.gov/travel) for more specific information about the country or countries to which you'll be traveling.

Also, if you're located in Southern California and you have questions, consider contacting the Santa Ana Health Department at 714-557-5599 or 714-647-0401 for a consultation on what vaccinations you'll need. You should make an appointment as soon as possible as often there's a waiting period to schedule a time to meet.

If located elsewhere, look up your local health department to do the same.

First Name *
Your answer
Middle Name
Your answer
Last Name *
Your answer
Cell Number *
Please provide your mobile number here.
Your answer
Your Height *
Your answer
Your Weight *
Your answer
Date of Birth *
MM
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DD
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YYYY
Have you taken out medical insurance that will cover you while traveling and/or that will provide evacuation in the case of an emergency? *
We strongly recommend that you purchase medical and/or travel insurance to protect your health and your investment in this trip. See this link for a free quote: https://photoenrichment.com/products/travel-insurance/
If yes, please provide that information, including all contact info.
Your answer
Please evaluate your overall health. *
How would you rate your general level of stamina? *
Do you have any medical conditions or physical limitations we should be aware of? *
If you answered YES above, please explain in more detail.
Your answer
What is your blood type? *
Please list any medication(s) you are currently taking and in what dosage(s).
Your answer
Do you have any food allergies or dietary restrictions that we should be aware of?
Your answer
Emergency Contact Name *
Your answer
Emergency Contact telephone number. *
Your answer
Emergency Contact telephone number - alternate.
Your answer
Emergency Contact email address.
Your answer
Primary Doctor's Name *
Your answer
Primary Doctor's telephone number. *
Your answer
Is there anything else you'd like us to know related to your medical information?
Your answer
I certify that I have provided all necessary health information on this form and that my participation in this program won't pose an unnecessary risk to myself or others. *
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