KB Medical Form
Flips & Friends
Participant's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
1. Is there a condition that would preclude or limit the child's participation in our program?
*
Please Select
Yes
No
If you answered YES above, please explain:
2. Has the participant ever been informed they have asthma?
*
Please Select
Yes
No
If you answered YES above, please explain how it is controlled with medication:
3. Has the participant ever been informed they have epilepsy, and/or ever experienced a seizure?
*
Please Select
Yes
No
4. Has the participant ever been treated for infectious mononucleosis, viral pneumonia, or another infectious disease during the past 12 months?
*
Please Select
Yes
No
5. Has the participant ever been treated for or informed by a medical doctor they have a heart problem, a heart murmur, or high blood pressure ?
*
Please Select
Yes
No
6. Has the participant ever been told they had hemophilia or other bleeding disorders or currently have easy bleeding or brusing?
*
Please Select
Yes
No
7. Has the participant ever been told they have a hernia?
*
Please Select
Yes
No
If you answered YES above, has it been repaired?
Please Select
Yes
No
8. Has the participant had any operations in the past 2 (two) years?
*
Please Select
Yes
No
If you answered YES above, please explain when and the anatomical site:
9. Is the participant currently taking any prescribed medications?
*
Please Select
Yes
No
If you answered YES above, please tell us the name of the medication and what it's prescribed for:
10. Has the participant had a fracture in the past 2 (two) years:
*
Please Select
Yes
No
If you answered YES above, please indicate the site of the fracture and the date of the injury:
11. Has the participant had any joint dislocation in the past 2 (two) years:
*
Please Select
Yes
No
If you answered YES above, please indicate which joint:
12. Does the participant ever experience back pain?
*
Please Select
Yes
No
If you answered YES above, please select the frequency of the pain from the drop-down menu.
Please Select
Seldom
Occasionally
Frequently
Only with vigorous exercise or heavy lifting
13. Is the participant allergic to penicillin or any other medication?
*
Please Select
Yes
No
If you answered YES above, please list the medication/s:
14. Does the participant have any food allergies?
*
Please Select
Yes
No
If you answered YES above, please list the food/s:
15. Have there been any disciplinary, emotional, learning disabilities, or other concerns which we should be aware of? If yes, please explain.
PARENT/GUARDIAN: You attest that all of the above questions have been answered completely and truthfully to the best of your knowledge.
*
Parent/Guardian FULL NAME
Parent/Guardian Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: