NAME:___________________________________________________________________________________

MEDICAL FORM
QUESTIONS:

1. Are you allergic to any medications?__________ If so, what?______________________________________

2. Please list any other allergies:_________________________________________________________________

3. Have you ever had surgery?__________ Have you ever been hospitalized?____________________________

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4. Please list any disabilities or handicaps:__________________________________________________________

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5. Are you under the care of a physician for any medical problems?_____________________________________

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6. Do you take medication(s)?_________ If so, please identify:_______________________________________

7. Do you have any special medical needs that we should know about?_________________________________

Please specify:_______________________________________________________________________________

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