Medical History Form

Medical History & Dietary Requirements

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Thrive Adventures requests the following information in order to best serve you, and to be prepared in case of an emergency. Your safety and comfort are our priorities. Confidentiality is also paramount to us. We only require a response to your dietary needs which you can reply NONE if that is the case.

* Indicates required field

Name *

First

Last

Please list any dietary requirements and allergies: *

Please list allergies to medications, animals, and/or environmental/seasonal substances:

Allergens *

Description of Reaction *

Have you ever experience an allergic reaction with throat swelling or difficulty breathing? If yes, please describe the event and list the allergen:

Comment *

Do you carry an Epipen? *

Yes No

Please list any medical conditions that may limit your ability to perform mild to moderate activity (e.g. Hiking): *

Please list any medications you currently take, whether daily or on an intermittent basis: *

Submit