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MEDICAL INFORMATION AND RELEASE FORM
Date of Birth Age Place of Birth
Family Doctor’s Name Telephone Number
Name of Medical Insurance Group Number
Please answer the following question:
Are you in good physical condition? Yes No If no, please explain condition(s):
Are you currently taking any medication? Yes No
Medication name, dosages, frequently:
Date of last physical?
Name of health care professional who performed last physical exam?
Location where physical was done:
Special Needs: (check on the line)
Hearing Impaired Visually Impaired Learning Disability
Special Diet Physical Disability Prosthesis
Other: Explain _________________________________________________________________________________
In case of a medical emergency, who should we contact?
Parent/Guardian telephone number: Home Work
Significant other, who we may also contact? Name Relationship