MEDICAL INFORMATION FORM
The information provided in this form is confidential and will be used solely by authorized staff of King's School of Ministry to ensure the health, safety, and well-being of the student during their time in the program. This form allows staff to respond appropriately in the event of a medical situation, emergency, or ongoing health need. It may be shared with licensed medical personnel only if necessary for treatment. By completing this form, you acknowledge that all information is accurate to the best of your knowledge and that you give permission for KSM staff to act in your best interest in case of a medical emergency.
CONTACT INFORMATION
FULL NAME:
DATE OF BIRTH (MM/DD/YYYY):
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PHONE NUMBER:
Format: (000) 000-0000.
ADDRESS:
EMAIL:
example@example.com
INSURANCE INFORMATION
INSURANCE PROVIDER:
POLICYHOLDER NAME:
POLICY NUMBER / GROUP NUMBER:
INSURANCE PHONE NUMBER:
Format: (000) 000-0000.
CURRENT MEDICATIONS
NAME:
DOSAGE & FREQUENCY:
PURPOSE/REASON:
SELF-ADMINISTERED? YES / NO
YES
NO
ALLERGIES
FOOD ALLERGIES:
MEDICATION ALLERGIES:
ENVIRONMENTAL ALLERGIES:
REACTION DESCRIPTION:
CARRIES EPIPEN OR INHALER? YES / NO
YES
NO
MEDICAL CONDITIONS/HISTORY (MARK N/A OR EXPLAIN)
ASTHMA?
DIABETES?
SEIZURE DISORDERS?
HEART CONDITIONS?
MENTAL HEALTH CONCERNS?
PAST SURGERIES OR HOSPITILIZATIONS:
OTHER CHRONIC OR SERIOUS CONDITIONS?
Signature:
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