MARINE SCIENCES & TECHNOLOGY CENTER
MEDICAL OR SPECIAL NEEDS FORM
This information is to be completed by the PI or Chief Scientist for personnel within the scientific party that have various medical problems or special needs that the Connecticut crew should be aware of and MUST be submitted along with the cruise plan.
Health problems such as diabetes, high blood pressure, allergies and particular dietary needs must be reported, including the name, address and phone number of the physician most familiar with their medical history.
Any member of the scientific party using a prescription drug medication during the cruise must be included along with the name of the medication, dosage and physician who prescribed the drug.
NAME_________________________________ MEDICAL PROBLEM: _________________________
PRESCRIPTION MEDICATION(S): _______________________________________________________
PHYSICIAN(S) NAME, ADDRESS, PHONE #'S: _____________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
SPECIAL NEEDS/DIETARY CONSIDERATIONS: ___________________________________________
NAME_________________________________ MEDICAL PROBLEM: _________________________
PRESCRIPTION MEDICATION(S): _______________________________________________________
PHYSICIAN(S) NAME, ADDRESS, PHONE #'S: _____________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
SPECIAL NEEDS/DIETARY CONSIDERATIONS: ___________________________________________
NAME_________________________________ MEDICAL PROBLEM: _________________________
PRESCRIPTION MEDICATION(S): _______________________________________________________
PHYSICIAN(S) NAME, ADDRESS, PHONE #'S: _____________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
SPECIAL NEEDS/DIETARY CONSIDERATIONS: ___________________________________________
NAME_________________________________ MEDICAL PROBLEM: _________________________
PRESCRIPTION MEDICATION(S): _______________________________________________________
PHYSICIAN(S) NAME, ADDRESS, PHONE #'S: _____________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
SPECIAL NEEDS/DIETARY CONSIDERATIONS: ___________________________________________
NAME_________________________________ MEDICAL PROBLEM: _________________________
PRESCRIPTION MEDICATION(S): _______________________________________________________
PHYSICIAN(S) NAME, ADDRESS, PHONE #'S: _____________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
SPECIAL NEEDS/DIETARY CONSIDERATIONS: ___________________________________________
__________________________________________________________________________________________________________