Tampa Prep: IO Medical History

MEDICAL HISTORY

Inside Out (828)697-5295

Introduction
Please review this Document (hereafter 'Document') carefully before signing. All participants (hereafter 'participant' or 'participants') must sign this Document.

School or Group:
Participant:			Sex:
Age:			Date of Birth:

Student's Complete Home Address:
Address, Line 1:			Address, Line 2:
City:			Zip Code:

Contact Person(s):
Name:			Relationship:
Home Phone:			Work Phone:
Name:			Relationship:
Home Phone:			Work Phone:
Insurance Company:			Policy Number:

Mark each of the following items with regard to whether the participant currently has, or in the past has had, the condition. Use the space provided at the end to explain any "yes" answers. If the answer is "not in a while", mark "yes" and give approximate date since last occurrence: Please elaborate if necessary --on the back of this form.

	YES	NO	Comments
Allergic to insect bites or stings
Asthma
Bones/joints weakened by injury or illness
Heart
Conditions
High blood pressure
Medical care which limits activities
Mental or emotional disorders
Migraine headaches
Motion Sickness
Seizures
Last Tetanus Shot Date

Any other items not covered by the previous:

List in this space medicines to which participant is allergic: (please add severity)

Please list specific food allergies and their severity:

List in this space medicines which participant is currently taking for ANY reason, whether prescribed, or over the counter:

Does the parent or legal guardian allow the minor participant to receive non-prescription medicine for incidental headaches, sore throats, and/or upset stomachs, which may occur while participant is away from home:

Does the parent or legal guardian allow the minor participant to receive such treatment as may be immediately necessary in an emergency or life threatening situation?

______________________________________		______________________________________
(Signature of Parent/Legal Guardian)		(Date)

______________________________________		______________________________________
(Print Name)		(Relationship)