Prefix           Mr. Mrs. Miss Ms.

                            First Name 

                            Last Name   

                           Address      

                           City              

 

                          State 

                        Zip   

                    Phone Number  

Vacation Choice 

Traveler Profile

Date of Birth   

Gender             Select One Male Female

Height:              Feet    Inches  

Weight             

Please Answer Yes or No to the Following Questions

Handles Own Money                          Select One Yes No

Consumes Alcoholic Beverages      Select One Yes No

Verbal                                                  Select One Yes No

Wears Glasses                                   Select One Yes No

Uses Sign Language                         Select One Yes No

Wears Hearing Aid                            Select One Yes No

Gets Overheated Easily                    Select One Yes No

Uses a Wheelchair                            Select One Yes No

Requires Assistance With ADL's    Select One Yes No

Wears Dentures                                Select One Yes No

Can Walk Long Distances               Select One Yes No

Past Eating Disorder                        Select One Yes No

 

Needs Assistance Toileting             Select One Yes No

Wears Diapers                                  Select One Yes No

Describe Any Dietary Limitations  

Behavioral Issues                             

Physical Challenges                        

 

Favorite Meals                                 

Bathing Preference                           Select One Baths Showers

Allergies                                            

Medication