Application and Participant Health Record Participant Name: _______________________________ Date of Last Physical: _______________ Birth date:      Age: _______     Height:  _______     Weight:  _______     BP: _____________ Allergies (meds, food, etc.) _____________________________________________________________ Pertinent Past History (Illnesses, Surgeries, and Injuries):                                                                                                                                                                                     Chronic Illness: Vision: R 20/____ L 20/___       □ Color blind        □ Glasses            □ Contacts Hearing R      L                      Aid? … Continue reading Application for Project Belize