Medical/Dental Screening Form

  • Your General Info
Name*
Birth Date (Mo/Day/Yr)*
Mailing Address
  • Emergency Contact
Name*
Phone*
  • Your Medical Info
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.