Enclosure 1B: Medical Information Form

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Please provide accurate and up-to-date information about your medical history and current health status. This information is essential for ensuring your safety and well-being during the Epic Leader Retreat. Your personal information will be kept confidential and only shared with necessary retreat staff and medical professionals as required.

 

**Personal Information**

 

* Full Name:

* Date of Birth:

* Gender:

* Nationality:

 

**Medical History**

 

* List any significant past medical conditions, surgeries, or hospitalizations:

* Have you ever been diagnosed with a chronic disease or illness (e.g., diabetes, asthma, heart disease)? If yes, please specify:

 

**Current Health Status**

 

* Do you currently have any medical conditions, allergies, or physical limitations we should be aware of?

* Are you currently taking any prescription medications, over-the-counter medications, or supplements? If yes, please list them:

* Have you experienced any recent injuries or illnesses (e.g., broken bones, flu)? If yes, please provide details:

 

**Emergency Contact Information**

 

* Full Name:

* Relationship to you:

* Phone Number:

* Email Address:

 

By signing below, I confirm that the information provided in this Medical Information Form is accurate and complete to the best of my knowledge. I understand that this information is necessary for the retreat organizers to ensure my safety and well-being during the Epic Leader Retreat.

 

Signature: ____________________

Date: ___________________________