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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:












Required psychological

counseling or therapy?



Allergies (Seasonal)________




Heart Ailments



Hospitalized for a

psychological problem?



Liver Problems



Stomach or Intestinal Problems



Surgery other than 

tonsillectomy, hernia repair, appendectomy or wisdom teeth removal?






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






Pilonidal Cyst








Drug Abuse












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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