2026 JH Missions Confidential Medical Questionnaire

Confidential Medical Questionnaire

(Student)
Parent and Guardian Information
Parent/Guardian full name
Phone Number
Format: (000) 000-0000.
Address
Email
example@example.com
Relationship to Student
Alternate Emergency Contact
Full Name
Phone Number
Format: (000) 000-0000.
Relationship to student
Student Information
Last Name
First Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Biological Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
SSN (REQUIRED FOR MISSIONS STUDENTS ONLY)
Medical Information
Doctor's Name
Doctor's Phone number
Name of Medical Insurance Company
Rx Plan/number (if applicable)
Insurance Mailing Address
Policy or Group Number
Insurance Phone
Date of last Tetanus shot if known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PLEASE PROVIDE ANY PERTINENT MEDICAL INFORMATION
1. Are you presently under treatment for any medical problems?
If Yes:
2. Do you take any medications routinely? If yes, give name and dosage.
If Yes:
3. Have you ever been unconscious or had any head injuries?
If Yes:
4. Are you allergic to any medications or food? (Please list)
If Yes, please list
5. Have you ever had asthma, hay fever, hives, or eczema?
If yes, you need to have a "more-than-ample" supply of medication(s) with you.
6. Do you have any history of diabetes, hypoglycemia, or heart disease?
If Yes:
7. Have you had any recent illnesses, skin rashes, or sore throats?
If Yes:
8. Do you require any injections on a regular basis?
If Yes:
9. Are there any other medical conditions of which we should be aware?
If Yes:
10. Is there any other pertinent medical information you wish to include?
If Yes:
Signature
Date
Should be Empty:

Confidential Medical Questionnaire

Alternate Emergency Contact

Student Information

Medical Information

PLEASE PROVIDE ANY PERTINENT MEDICAL INFORMATION