EDINBURG POLICE DEPARTMENT CITIZEN POLICE ACADEMY

Participant's Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Important – The following must be completed for attendance.

The following questions are in regards to the participant. The below information will be given toany emergency medical technician (EMT), paramedic or health care professional providing treatment.The form will also be given to a doctor if an emergency room visit is recommended. Please fill outthe following questionnaire to the best of your knowledge and explain any medical conditions that yourchild may have, in full detail.

Have you had any recent injury, illness or infectious disease?*

YesNo

if yes, please explain*

Have you ever been hospitalized and/or had any surgeries?*

YesNo

if yes, please explain*

Do you have any orthopedic problems (i.e.: bones, joints, ligaments and muscles)?*

YesNo

if yes, please explain*

Do you have any physical limitations, or wear orthopedic braces?*

YesNo

if yes, please explain*

Asthma?*

YesNo

Headaches?*

YesNo

Ear Infections?*

YesNo

Fainting Spells?*

YesNo

Diabetes?*

YesNo

Heart Trouble?*

YesNo

Difficulty with Digestion?*

YesNo

Convulsions / Seizures?*

YesNo

If yes to any above, please explain*

EDINBURG POLICE DEPARMENT

HEALTH & EMERGENCY CARE FORM

MEDICAL HISTORY