Medical/Dental Screening Form

Name*

Birth Date (Mo/Day/Yr)*

Sex*

Mailing Address

Name*

Phone*

Check all that applies to you

Past Injuries

Diabetic

Currently taking medication prescibed, over-the-counter, inhaler, or psychatric*

Currently taking medication: list medication(s), reason for taking medication(s), and any side effects

Allergies: food, medicine, or environmental*

Allergies: list allergies, reaction, and medication required.

Other medical condition (mental, physical, or emotion) that may influence your behavior.*

Please complete the required fields.