| Name | John Burnham |
|---|---|
| Date of Birth | 05/21/1956 |
| Age | 65 |
| Address | 88 Oliphant Lane Middletown, RI 02842 United States Map It |
| Mobile Phone | (401) 835-2686 |
| Email hidden; Javascript is required. | |
| I am a competent swimmer | Yes |
| In Case of Emergency | Please provide an Emergency Contact |
| Name | Rachel Balaban |
| Relationship | spouse |
| Mobile Phone | (401) 261-7062 |
| Email hidden; Javascript is required. | |
| Comments | She is my better half. |
| Health History | The following information is requested. This information will be kept confidential and shared only when as deemed needed. Any changes to this information must be provided to the boat captain. Please provide complete information, so that we can be aware of your needs. |
| COVID-19 Vaccine | Yes |
| Allergies | None significant |
| Dietary Restrictions | None |
| Medications Being Taken | YES, Medications as follows |
| Medications Taken | warfarin 7.5mg daily, etc. |
| Do you have a history of Asthma? | No |
| Do you have a history of seizures? | No |
| Are you Diabetic? | No |
| Do you have abnormal blood pressure or a history of heart disease? | Yes |
| Have you ever had an anaphylactic reaction? | No |
| Blood Type if known | A- |
| If you answered Yes, please explain. | HCM |
| Food Preferences | Please check those you like & add comments where necessary |
| Food Likes |
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| Breakfast | Hearty |
| Bar Preferences |
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| Other Additional Information | This is a test of the new form on the MySerena.org website. |