Wilderness Reflections Health Questionnaire- Wilderness Quests

  • These questions are designed to protect your health and safety. Please answer them completely and candidly, using the reverse side of the page as needed.
  • Date Format: MM slash DD slash YYYY
    If yes, for what?
    Dates?
    If yes, please explain
    If yes, please specify any such allergies
    If yes, please specify
    Have you recently? If yes, please specify
  • (if under 18, signature by parent or legal guardian grants consent to treatment)