Pilgrimage Medical Information Disclosure Form
Personal Information
Full Name
Date of Birth
Passport Number
Phone Number
Emergency Contact Name & Number
Medical History
Do you have any chronic illnesses?
Diabetes
Hypertension
Asthma
Heart Disease
Other
If other, please specify / Details:
Are you currently taking any medication?
Yes
No
If yes, list medications:
Allergies (medication, food, etc.):
Other relevant medical information:
Consent
I certify that the above information is complete and accurate to the best of my knowledge. I authorize the pilgrimage organizers to disclose this information to relevant medical personnel in the event of an emergency.
Signature
Date