Fits_medical_form

Date _______________
Name ______________________________________________ Home Congregation _______________________
Parent/Guardian __________________________________________________________________________________
DOB _______________ Age _______________ Sex Male Female
Personal Physician ___________________________________ Telephone (____) __________________________
Please explain any “yes” answers:
1. Have you ever been hospitalized? Yes No
2. Are you presently taking any medications or pills (including vitamins, inhalers, OTC meds)? Yes No
3. Do you have any allergies (medications, foods, bees, stinging insects)? Yes No
4. Have you ever passed out during exercise? Yes No
5. Do you have any skin problems (itching, rashes)? Yes No
6. Have you ever had a head injury? Yes No
7. Have you ever been knocked out or unconscious? Yes No
8. Have you ever had a seizure? Yes No
9. Have you ever had heat or muscle cramps? Yes No
10. Have you had problems with your eyes or vision? Yes No
11. Have you ever sprained, dislocated, fractured, broken or had repeated swelling of any bones or joints? Yes No
12. Have you had a medical problem since your last evaluation? Yes No
13. When was your last tetanus shot? ______________________________
14. Have you ever had chicken pox? Yes No If no, have you received the vaccine? Yes No
15. When was your last physical exam? _____________________________
16. Do you have any chronic medical conditions (i.e.: asthma, diabetes, depression, anxiety)?
17. Do you have any dietary restrictions?
18. How would you describe your present state of health?
19. Is there any specific information you would like us to know?
I hereby state that, to the best of my knowledge, the above answers are correct.
Signature of youth Signature of parent/guardian Date
Thank you for this information. It will remain confidential with our medical volunteer and will be destroyed after your FITS TEC retreat.
Youth Name _____________________________________________________________________________________
I
If I have a medical emergency during the retreat, please contact the following family member:
Name ___________________________ Phone _____________________ Other Phone ________________________
In case the above person is not available, please contact the following:
Name ___________________________ Phone _____________________ Other Phone ________________________
Name ___________________________ Phone _____________________ Other Phone ________________________
II
AUTHORIZATION TO OBTAIN MEDICAL TREATMENT FOR A MINOR
As parent/legal guardian of _________________________________________________, a minor, I do hereby authorize and give
permission to the medical volunteer or an adult chaperone with FITS TEC to seek and obtain any medical services that in their judgment
my child may need while participating in FITS TEC. It is my understanding that I will be contacted as soon as possible, but not
necessarily prior to treatment that might be emergent. I further understand and agree that I will be responsible for any such incurred
medical costs.
Signature of parent/guardian Date
III
My initials below indicate my child may receive the following non-emergency medical treatment from any adult affiliated with
FITS TEC, as deemed appropriate:
_____ Acetminophen (e.g. Tylenol)
_____ Ibuprofin (e.g. Motrin)
_____ Naproxen Sodium (e.g. Aleve)
_____ Antihistamines (e.g. Benadryl)
_____Decongestant (e.g. Sudafed)
_____ Sore throat spray (e.g. Chloraseptic)
_____ Cough lozenges (e.g. Halls Cough Drops)
_____ Cough medicine (non-narcotic, e.g. Delsym)
_____ Antacids (e.g. Malox)
_____ Anti-diarrheal medication (e.g. Imodium)
_____ Basic First Aid (e.g. disinfecting cream, topical ointment, sunburn lotion, etc.)
IV
Medical Insurance Company ______________________________________________________
Policy #_______________________________________________________________________
Group #_______________________________________________________________________
FITS TEC – Health Form, Revised November 2011

Source: http://www.fitstec.org/documents/FITS_Medical_Form.pdf