SAMPLE MEDICAL FORM, HEALTH HISTORY, IMMUNIZATIONS, EMERGENCY TREATMENT INSERT PROGRAM DESCRIPTION HERE INSERT CONTACT INFORMATION FORM HERE PART I — HEALTH HISTORY Please check any of the following that apply and note next to each the diagnosis and date...
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SAMPLE MEDICAL FORM, HEALTH HISTORY, IMMUNIZATIONS, EMERGENCY TREATMENT INSERT PROGRAM DESCRIPTION HERE INSERT CONTACT INFORMATION FORM HERE PART I — HEALTH HISTORY Please check any of the following that apply and note next to each the diagnosis and date when the condition started. 1. ALLERGIES/ADVERSE REACTIONS TO MEDICATIONS/FOOD/INSECTS/OTHER? □ No □ Yes—please specify... 2. DO YOU TAKE ANY MEDICATIONS ON A FREQUENT OR REGULAR BASIS? □ No □ Yes—please list... Please list ALL prescription AND nonprescription medications AND supplements: 3. HAVE YOU EVER HAD ANY HEALTH PROBLEMS, SURGERIES/OPERATIONS, OR HOSPITALIZATIONS? Check each item: No Yes Diagnosis/ Check each item: No Yes Diagnosis/ Date Date Appendectomy Epilepsy/Seizure Disorder Asthma Heart condition, disease, or murmur Attention Deficit/Hyperactivity Dis. HIV test Positive or AIDS Chicken Pox/Varicella Migraine Headaches Depression or Anxiety (specify) Mononucleosis/Epstein-Barr Virus Diabetes Mellitus Splenectomy Eating Di
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