2018 PAUMCS Conference Medical Form
We want to be attentive to the health and safety needs of attendees at our Conference. One of the ways we can do that is to have available Medical Information from all participants in the event of an emergency. Your response will be kept with Nancy Gardner, Registrar, at the registration table. The form will be kept confidential and will be destroyed after the conference.

Where your answer is No, None or Not Applicable please type something to confirm you have read the question.

Conference Participant Name *
Your answer
Your cell phone number or how you may be contacted during Conference *
Your answer
Are you currently under a doctor’s care for a specific illness (heart, recent surgery, etc.)? If yes, please explain *
Your answer
MEDICATIONS
List of medication(s) you are taking during Conference *
Your answer
Where is the above listed medication located?
ALLERGIES
Are you allergic to any medication? If yes, please explain *
Your answer
Do you have any other allergies (food, bees, etc.)? If yes, please explain *
Your answer
EMERGENCY CONTACT
Name of roommate at the Conference or confirm no roommate or not staying at Nashville Airport Marriott *
Your answer
Room Number (Hotel will provide to Registrar)
Your answer
Name of person to contact in case of emergency *
Your answer
Cell phone number of person to contact in case of emergency *
Your answer
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