Confidential Medical Questionnaire(Student)
Parent and Guardian Information
Parent/Guardian Name
First Name
Last Name
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Student:
Alternate Emergency Contact
Full Name:
First Name
Last Name
Phone Number:
Format: (000) 000-0000.
Relationship to Student:
Student Information
Student Name
First Name
Last Name
Birth date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Biological Gender:
Primary Phone:
Format: (000) 000-0000.
Address (if different from above):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Information
Doctor's Name:
First Name
Last Name
Doctor's Phone:
Format: (000) 000-0000.
Name of Medical Insurance Company:
Rx Plan/number (if applicable):
Insurance Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy or Group Number:
Insurance Phone:
Format: (000) 000-0000.
Date of last Tetanus shot if known:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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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?
2. Do you take any medication(s) routinely? (If yes, give name and dosage)
3. Have you ever been unconscious or had any head injuries?
4. Are you allergic to any medications or food? (Please list)
5. Have you ever had asthma, hay fever, hives, or eczema?
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?
7. Have you had any recent illnesses, skin rashes, or sore throats?
8. Do you require any injections on a regular basis?
9. Are there 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
2 digit month, 2 digit day, 4 digit year
Date
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