JUC Youth Medical Form

Medical Form

Fill out your medical information carefully
Youth Name

First NameLast Name
Birth Date

MonthDayYear
General Medical History
YesNo
FoodMedicationEnvironmental
Please list and explain any allergies
Significant Medical History (surgery, injuries, serious illness):
List any Medical Problems (asthma, seizures, headaches):
YesNo
List any medication taken regularly:
Dosage
Please list how medication should be taken and at what time(s)
ex. 1 pill at 10 AM everyday
Purpose of medication
List any side effects
I authorize the facilitators of this group to provide medication setup and/or medication administration (prescription medications, including psychotropic medications, and over-the-counter medications) or treatments to my child(ren) ordered by a health care professional.
Signature

Clear
Should be Empty:

Medical Form