NAME:___________________________________________________________________________________ MEDICAL FORM 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?_______________________________ _________________________________________________________________________________________ 4. Please list any disabilities or handicaps:__________________________________________________________ __________________________________________________________________________________________ 5. Are you under the care of a physician for any medical problems?_______________________________________ __________________________________________________________________________________________ 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:_______________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ |
