Fillable Stud Med Info Interactive Form (Weatherford College)

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Stud Med Info Interactive Form (Weatherford College)

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The Stud Med Info Interactive Form (Weatherford College) form is 1 page long and contains:

  • 1 signature
  • 39 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Weatherford College

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Weatherford College Upward Bound
MEDICAL INFORMATION
Student’s First Name
Student’s Last Name
Date
YES
NO
Please list:
Describe any medical problems UB should be aware of, such as asthma, allergies, or other medical conditions (use back page if
needed):
Does the student use an inhaler?
YES
NO
Does the student use an epi-pen?
YES
NO
YES
NO
Is the student currently taking any prescription medications or long term medications?
Name of Drug
Dosage
Purpose
If needed, is UB authorized to administer any over the counter medications?
YES
NO
(Headache medication, Pepto-Bismol, Benadryl)
Briefly describe any limitations on the student’s physical activity:
Please mark any foods that your student is allergic to and or should avoid because of dietary restrictions:
Dairy (milk, ice-cream, cheese, etc.)
Soy
Berries
Peanuts
Chocolate
Yeast
Eggs
Garlic
Chili
Tomatoes
Sesame Seeds
Corn
Oranges/Juice
Pork
Pistachios
Pine Nuts
Apples
Grapefruit/ Juice
Fish
Tree nuts (Almonds, Walnuts, etc.)
Shellfish (shrimp, lobster, crab, etc.)
Wheat/gluten/Oats
Pineapple
Beans/Legumes
Onions
Kiwi
Sunflower Seeds
Spinach
Chicken
Beef
Rice
Potatoes
Coconut
Other allergic foods not listed (please print clearly)
Signature of Parent/Guardian
Date
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signature
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Stud Med Info Interactive Form (Weatherford College)

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Completed 7 October 2020

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