Confidential Medical Questionnaire
Child
Parent and Guardian Information
Full Name
Phone Number
Email:
example@example.com
Address
Relationship to child:
Child Information
First Name:
Last Name:
Birth date:
-
Month
-
Day
Year
Date
Biological Gender
Please Select
Male
Female
Phone Number:
Address (if different from above):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Alternate Emergency Contact
Full Name:
Phone Number:
Relationship to child:
Medical Information
Doctor's Name:
Doctor's Phone:
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:
-
Month
-
Day
Year
Date
Back
Next
Please include any pertinent medical information.
IF YOU ANSWER YES TO ANY QUESTION, PLEASE PROVIDE ADDITIONAL EXPLANATION
1. Are you presently under treatment for any medical problems?
Please Select
Yes
No
If yes, please explain
2. Do you take any medication(s) routinely?
Please Select
Yes
No
2. (If yes, give name and dosage)
3. Have you ever been unconscious or had any head injuries?
Please Select
Yes
No
If yes, please explain and provide dates
4. Are you allergic to any medications or food?
Please Select
Yes
No
If yes, please list
5. Have you ever had asthma, hay fever, hives, or eczema?
Please Select
Yes
No
If yes, you need to have more-than-ample supply
of medication(s) with you.
6. Do you have a history of diabetes, hypoglycemia, or heart disease?
Please Select
Yes
No
If yes, please explain.
7. Have you had any recent illnesses, skin rashes, or sore throats?
Please Select
Yes
No
If yes, please explain.
8. Do you require any injections on a regular basis?
Please Select
Yes
No
If yes, please explain
9. Please describe any other medical conditions of which we should be aware.
10. Is there any other pertinent medical information you wish to include?
Signature
Date
-
Month
-
Day
Year
Date
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