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
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.

Do you use OXYGEN?
*If you use oxygen, a medical team member will be in contact with you.
Do you use a NEBULIZER for breathing problems?
(you may bring this with you)
Do you have CONGESTIVE HEART FAILURE?
Do you have PACEMAKER/DEFIBRILLATOR?
Do you have DIABETES?
Do you have SEIZURES?
If yes, a member of our medical team will contact you.
Do you have DEMENTIA/MEMORY PROBLEMS/BEHAVIORAL ISSUES?
If the veteran has dementia/memory issues, additional accommodations need to be discussed
*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?
*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.