The Prophet's Path Medical Questionnaire Confidential Medical QuestionnaireThe Prophet's PathHummingbird Music CampOct 1st – Oct 5th, 2025 If you are registering for The Prophet's Path: Evolution of the Male Journey — you must complete this confidential Medical Form. (PLEASE ANSWER ALL QUESTIONS) Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Best Time to Call * Morning (8a - 12p) Afternoon (12p - 4p) Evening (4p -8p) Anytime Date of Birth * MM DD YYYY Emergency Contact Information First Emergency Contact * First Name Last Name Relationship to Contact * First Contact Phone * (###) ### #### Second Emergency Contact * First Name Last Name Relationship to Contact * Second Contact Phone * (###) ### #### Confidential Medical Questions We respect your privacy. All of the information you provide is kept confidential. Please answer these questions thoroughly and to the best of your knowledge. Height * e.g. 5' 10" Weight * Just enter a number in pounds - e.g. 190 Do you have specific food or nutritional requirements? * Check all that apply. Vegetarian Gluten free Lactose intolerant Other If you check any of the above, please comment: * Do you have any of the following conditions? Epilepsy * Yes No Bleeding/Clotting Disorder * Yes No Heart Attack * Yes No Heart Disease * Yes No Heart Murmur * Yes No Asthma * Yes No Emphysema * Yes No High Blood Pressure * Yes No Diabetes * Yes No Hypoglycemia * Yes No Lung Disease * Yes No Siezures of Any Kind * Yes No Anaphylactic Shock * Yes No Other conditions we should know about? * Yes No If you checked YES to any of the above, describe your conditions: Have you experienced allergic reactions to any of the following? Environmental Substance * Yes No Foods * Yes No Drugs * Yes No Insect Bites or Stings * Yes No Other * Yes No If you checked YES to any of the allergic reactions above, describe your conditions: Do you carry an EpiPen? * Yes No Do you have any disabilities or significant restrictions in any of the following areas? Back * Yes No Knees * Yes No Hips * Yes No Ankles * Yes No Other * Yes No If you checked YES to any of the above, describe your conditions: Based on your past, if you walked on a level survace for a mile at a moderate pace, would you experience any of the following? Shortness of Breath * Yes No Chest Pain * Yes No Leg Pain * Yes No Other * Yes No If you checked YES to any of the above, please comment: Are you taking any prescribed medications at this time? * Yes No If YES, please list each medication, dosage and condition being treated. Please assess your physical fitness: * Excellent Good Average Fair Poor Are you currently (or within the past two years) receiving treatment from a physician or other health care professional for any physical or physcological reason? * Yes No If you checked YES to any of the above, describe your conditions: Date of your last tetanus shot? * MM DD YYYY Have you ever been told that your snoring is serious enough that it can disturb others? * Yes No Do you use a CPAP machine? * Yes No Will you require assistance with any specific medical condition while you at at this retreat? * You will be contacted by the medical director to make arrangements. Yes No If you answered YES, please describe: Is there anything else you feel we should know about you (your history or any other physical or emotional conditions) to help us support you during your time with us? Please specify: I authorize the New Mexico staff to furnish the information that I have completed above to medical professionals providing me emergency care during this event. * Yes, I authorize New Mexico to release this medical information in the event of an emergency. No, I do not authorize New Mexico to release this medical information in the event of an emergency. Upon arrival at the retreat, you will be provided with a printed copy of this form for your signature. We respect your privacy. All of the information you've provided is kept confidential. Thank you very much for completing the Confidential Medical Questionnaire. This is essential for ensuring the health and safety of every man participating in the upcoming Prophet's Path: Evolution of the Male Journey. Your responses will be kept confidential and a representative will be contacting you regarding any special needs or requests. Questions: Email our Coordinator Geno Gallegos desertskyg3@gmail.com
