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Medical History Form

Medical History

Orthodox Youth Retreat

Name of Youth/Young Adult Participant:________________________________

Does your youth suffer from or has he/she been treated for any of the following:

YES

NO

 

YES

NO

 

 

 

Asthma

 

 

Required psychological

counseling or therapy?

 

 

Allergies (Seasonal)________

Diabetes

 

 

Heart Ailments

 

 

Hospitalized for a

psychological problem?

 

 

Liver Problems

 

 

Stomach or Intestinal Problems

 

 

Surgery other than 

tonsillectomy, hernia repair, appendectomy or wisdom teeth removal?

 

 

Cancer

 

 

High Blood Pressure

 

 

Joint or Back Problems

 

 

Kidney Problems

 

 

Under the care of a doctor or other practitioner for any

reason other than healthy child visits?

 

 

Epilepsy or other neurological problem

 

 

Eye Problems

 

 

Lung Problems

 

 

Thyroid Problems

Known Medical Allergies: Allergic Reactions to food/s, animals, insects, medications and/or to the environment. Please clearly indicate  on lines below:

 

 

Skin Disease

 

 

Hernia

 

 

Pilonidal Cyst

 

 

 

Alcoholism

 

 

 

Drug Abuse

 

 

 

ADD/ADHD

 

 

 

Autism

 

 

 

Is your child up-to-date on all required immunizations?

List Additional Medical Concerns

On the Participant’s Permission Slip/Insurance Form, “Notes”

Other Important Information:

 

 

I hereby state that, to the best of my knowledge, all information indicated above is correct.

Name of Parent/Guardian (Please Print):___________________________________________

Signature of Parent/Guardian: ___________________________________________________    

Date: ________________

 

 

 

 

¡Gloria a Dios por todo!
Direct your Questions, Comments or Feedback to (Por favor dirigir sus preguntas, dudas o comentarios al): 956-781-6114 or info@stgeorgepantry.org


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