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: ________________