TFT Trauma Relief Interest Form
First Name:
Last Name:
Email:
Birth Date:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Mobile Phone:
Pager:
Passport Number
Country
Medical History
Health Insurance Carrier:
Address:
City:
State:
Zip:
Country:
Group Name
/
Number:
Subscriber Name
/
Number:
Doctor's Name:
Phone:
Address:
City:
State:
Zip:
Country:
Current Medications and Medication Allergies:
Food and Other Allergies:
Immunizations
Date
Date
Date
Date
DTP
MMR
Plague
Polio Booster
Oral Polio
Tetanus
Typhus
Other
Height:
Weight:
Please indicate if you can perform the following tasks:
Yes
No
Lift and carry 20 pounds repeatedly
Lift and carry 50 pounds repeatedly
Climb 2 or more flights of stairs
Stand for 2 hours periods
Sit for long periods
Walk on uneven terrain
Walk for 2 hours
Drive in daylight
Drive at night
Bend and stoop
Sleep on a cot or floor
Work and live with little/no privacy
Tolerate extreme heat and humidity
Require air conditioning
Tolerate extreme cold
Tolerate smoke or poor air quality
Work 12 hour shifts/nights/weekends
Tolerate exposure to mass casualties/death
Require special food items/diet/timing of meals
Require electricity for medical devices/meds
Require access to specialized medical care
Require assistance with health monitoring
others:
World Health Organization - International High Risk Travel Areas -
www
.who.int/ith/en/index.html
