Medical/Dental Screening Form
Your General Info
Name
*
Birth Date (Mo/Day/Yr)
*
Sex
*
Male
Female
Mailing Address
Emergency Contact
Name
*
Phone
*
Your Medical Info
Check all that applies to you
Medical Device (hearing aide, prosthetic, bone brace, etc...)
Pregnant
Smoker
Diagnosed with high blood pressure
Diabetic
Seizures
Experienced a heart attack or heart condition
Had past injuries
Past Injuries
Back
Shoulder
Knee
Neck
Ankle
Other
Diabetic
Requiring Medication
Currently taking medication prescibed, over-the-counter, inhaler, or psychatric
*
Yes
No
Currently taking medication: list medication(s), reason for taking medication(s), and any side effects
Allergies: food, medicine, or environmental
*
Yes
No
Allergies: list allergies, reaction, and medication required.
Other medical condition (mental, physical, or emotion) that may influence your behavior.
*
Yes
No