MEDICAL AND PERSONAL INFORMATION. (Vehicle info needed for "On-the-Go" GPS Systems) Is Subscriber Ambulatory? ❑ Yes ❑ No Check all that apply: ❑ Xxxxxx ❑ Cane ❑ Wheelchair ❑ Scooter Medical Conditions/Physical Limitations: Medications: Allergies: Preferred Hospital: Hospital City and State: Hospital Phone Number: ( ) Primary Care Physician Name: Physician Phone Number: ( ) Height: Weight: Hair Color: Ethnicity: Preferred Language: VEHICLE INFO: Make: Model: Color: Plate#:
