Kadey-Krogen Yachts 5814, Owner'S Manual, Page: 411 / 449

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Krogen 58’ Manual, Hull 58014 Appendix K - Health Information Form
393
Appendix K - Health Information Form
Fill out a health information form for each person in your party and include it with your
Float Plan (Appendix - L) to facilitate medical assistance in the event of an emergency.
We have provided additional copies of the form that you may photo copy and fill out for
each person in your party.
NAME: ________________________________________________________________
EMERGENCY CONTACT: _______________________________________________
FAMILY DOCTOR: _____________________________________________________
Age: _____ How would you rate your general health? Excellent Good Fair Poor
PRESENT HEALTH CONCERNS:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
MEDICATIONS:
List any prescription and non-prescription medicines you are taking.
Medication Dose Times per day Date Started
__________________________ _________________ _______________ ___________
__________________________ _________________ _______________ ___________
__________________________ _________________ _______________ ___________
__________________________ _________________ _______________ ___________
__________________________ _________________ _______________ ___________
__________________________ _________________ _______________ ___________
__________________________ _________________ _______________ ___________
ALLERGIES OR REACTIONS TO MEDICINES:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
MOST RECENT IMMUNIZATIONS:
Tetanus (Td)__________ Others_____________________________________________
OTHER PERTINENT MEDICAL INFORMATION:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________