HEALTH AND MEDICAL QUESTIONNAIRE
Student’s Name: _____________________________________________________________ Sex ______ Date of Birth ____/____/____
Last First MI
Present Address: _______________________________________________________________________________________________
Street City State Zip
Parents or Legal Guardians: ______________________________________ Home #: _________________ Cell #: _________________
Other Emergency Contact: _______________________________________ Home #: _________________ Alternate #: _____________
Health Insurance Co.: ______________________________Policy Number: _________________ Health Ins. Tel. #______________
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Medical History of Student: (Please check Yes or No) ** Please check medication your child can receive
Yes No Yes No Yes No Diabetes ____ ____ Dizziness ____ ____ Acetaminophen (Tylenol) ____ ____ Drug Allergies ____ ____ Convulsions ____ ____ Ibuprofen (Advil) ____ ____ Asthma ____ ____ High Bld Pressure ____ ____ Throat Lozenges/cough drops____ ____ Epilepsy ____ ____ Heart Disease ____ ____ Antacids (Tums) ____ ____ Fainting Spells ____ ____ Stomach Disorder ____ ____ Lotions, Creams, ointments ____ ____ Kidney Disease ____ ____ Hay Fever ____ ____ Diphenhydramine (Benadryl) ____ ____ Liver Disease ____ ____
_______________________________________ Parent/Guardian Signature
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Surgery/ies (within the last year): _________________________________________________________________________________
Emotional problem (i.e. hyperventilation, hysteria): __________________________________________________________________
Serious medical problems not mentioned above: _____________________________________________________________________
Tetanus (last injection date): ___________________Allergies to drugs: __________________________________________________
Allergies to foods & other agents: ________________________________________________________________________________
List ANY medications the student might have cause to use on a trip (i.e. anti-convulsive, anti-histamine, insulin, any tranquilizer, etc.)
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Please describe any medical/mental problems which the student might have which have not been covered on this form and about
which you think the directors should know.
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