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[email protected]
701-220-1568

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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 April 2024 Flight

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 a history of OPEN HEAD INJURIES? *

Yes
No

Do you have EAR PROBLEMS? *

Yes
No

Do you have GLAUCOMA or ELEVATED EYE PRESSURE? *

Yes
No

If yes to any of these, please describe:

Do you have any other medical conditions we should be aware of?

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.

Do you have a Living Will/Advanced Directive? *

Yes
No

If yes, select yes, then attach to this application if possible.

File Upload for Living Will/Advanced Directive

Click or drag files to this area to upload. You can upload up to 2 files.

Allowed file types .jpg, .doc, .docx, .pdf

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]

701-220-1568

Serving Our Vets

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