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 |
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| Asthma |
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| Required psychological counseling or therapy? |
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| Allergies (Seasonal)________ Diabetes | |||
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| Heart Ailments |
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| Hospitalized for a psychological problem? |
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| Liver Problems | |||
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| Stomach or Intestinal Problems |
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| Surgery other than tonsillectomy, hernia repair, appendectomy or wisdom teeth removal? |
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| Cancer | |||
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| High Blood Pressure | |||
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| Joint or Back Problems | |||
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| Kidney Problems |
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| Under the care of a doctor or other practitioner for any reason other than healthy child visits? |
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| Epilepsy or other neurological problem | |||
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| Eye Problems | |||
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| Lung Problems | |||
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| Thyroid Problems | Known Medical Allergies: Allergic Reactions to food/s, animals, insects, medications and/or to the environment. Please clearly indicate on lines below: | ||
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| Skin Disease | |||
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| Hernia | |||
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| Pilonidal Cyst |
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| Alcoholism |
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| Drug Abuse |
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| ADD/ADHD |
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| Autism |
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| 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:
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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: ________________
