Honoring America's Veterans

[email protected]
701-805-9552

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Pre-Flight – Medical Form

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Pre-Flight Forms
Pre-Flight – Medical Form

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Only complete this form if you have been selected for the September 2024 Flight.

ALL PRE-FLIGHT FORMS MUST BE COMPLETED BY: JUNE 25, 2024.

Pre-Fligh Medical / Medications Form

Name *

First

Middle

Last

Email *

Entering a valid email will allow the Western ND Honor Flight to send you an email confirmation after this form has been submitted.

This information is necessary so that we may provide you with appropriate medical support during your trip. This information is for the Honor Flight medical team only and will remain confidential. Your responses to these questions will not affect your eligibility. Please fill out this page completely. If something does not apply to you, please write N/A or NONE. Do not leave any questions blank.

List any drug allergies and what type of reaction for each individual drug?

List any food allergies and what type of reaction for each individual food item?

Do you use OXYGEN? *

Yes
No

*If you use oxygen, a medical team member will be in contact with you.

How many liters?

How often?

Continuous
With activity only
At night only
With CPAP

Do you use a NEBULIZER for breathing problems?

Yes
No

(you may bring this with you)

Do you have CONGESTIVE HEART FAILURE? *

Yes
No

Do you have PACEMAKER/DEFIBRILLATOR? *

Yes
No

Do you have DIABETES? *

Yes
No

Do you use *

PILLS
INSULIN
NOTHING

Do you have SEIZURES? *

Yes
No

If yes, a member of our medical team will contact you.

Do you have DEMENTIA/MEMORY PROBLEMS/BEHAVIORAL ISSUES? *

Yes
No

If the veteran has dementia/memory issues, additional accommodations need to be discussed

If yes to any of the above questions, please describe:

Please list other medical conditions:

*If yes to any of the above questions, a medical team member may contact you.

Do you think you may need a wheelchair for this trip for any amount of time? *

Yes
No

*Walkers or motorized scooters are not allowed. Canes ARE allowed. We will gladly provide you with a wheelchair for any amount of time you need it.

EMERGENCY CONTACT

Name *

First

Last

Relationship *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Day Phone *

Emergency Contact Email *

Evening Phone *

Cell Phone

ALTERNATE CONTACT INFORMATION

(different from your emergency contact above)

Name *

First

Last

Relationship *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Day Phone *

Alternate Contact Email *

Evening Phone *

Cell Phone

MEDICATIONS

List each of your medications separately in the below boxes

Layout

Medication 1

Medication 3

Medication 5

Medication 7

Medication 9

Medication 11

Medication 13

Medication 2

Medication 4

Medication 6

Medication 8

Medication 10

Medication 12

Medication 14

Useful Links

National Honor Flight Site

Veterans Honor Flight of ND/MN

Western NDHF Intranet

Western NDHF Dashboard

Veterans Apps Page

Privacy Policy

View Our Privacy Policy

Contact Us

Western ND Honor Flight
PO Box 265
Bismarck, ND 58502

[email protected]

701-805-9552

Serving Our Vets

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