Confidential Medical Questionnaire for jotform

Confidential Medical Questionnaire

Costa Rica January 2026
Full Name of student
Birth date of student

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security number of student
Primary Phone
Doctors Name
Doctor's Phone
Name of Medical Insurance Company
Rx Plan/number if applicable
Insurance Mailing Address
Policy or Group Number
Insurance Phone
In case of emergency, contact:
Name
Phone
Relationship
Date of last tetanus shot

MonthDayYear
Date
Signature of Parent of legal guardian

Clear
Date

MonthDayYear
Date
Relationship to student
ALL questions must be completed. Please include any other pertinent medical information.
1. Are you presently under treatment for any medical problems?

YesNo
If yes please explain
2. Do you take any medication(s) routinely?

YesNo
If yes give name and dosage
3. Have you ever been unconscious or had any head injuries?

YesNo
If yes please explain
4. Are you allergic to any medications or food?

YesNo
If yes please explain
5. Have you ever had asthma, hay fever, hives, or eczema?

YesNo
If yes, you need to have a more-than-ample supply of medication(s) with you.
6. Do you have a history of diabetes, hypoglycemia, or heart disease?

YesNo
If yes please explain
7. Have you had any recent illnesses, skin rashes, or sore throats?

YesNo
If yes please explain
8. Do you require any injections on a regular basis?

YesNo
If yes please explain
9. Are there any other medical conditions of which we should be aware?

YesNo
If yes please explain
Upon submission you will be re-directed to our payment portal.

IF YOU DO NOT WISH TO MAKE A PAYMENT AT THIS TIME, SIMPLY CLOSE THE WINDOW.

YOUR SUBMISSION WILL STILL BE PROCESSED.
Should be Empty: