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.
  • MM slash DD slash YYYY
    If yes, for what?
    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)