MEDICAL EXAMINATION To be answered by parent or guardian (Check one) DOES YOUR CHID HAVE OR EVER HAD: Date of Birth Applicant’s Date of examination 1. Sickle Cell Anemia? NO YES ………………………... 2. Food medication allergy? NO YES ………………….. Height Weight Blood Pressure 3. Epilepsy, seizures, fainting spells? NO YES …………. 4. Heat Stroke or heat exhaustion? NO YES ABNORMAL COMMENTS ……………. 5. Diabetes mellitus (sugar)? NO YES …………………. Eyes 6. Hemophilia (bleeding disorder)? NO YES ……………. Ears 7. Bone or joint problem? NO YES …………………….. Nose,Throat 8. Heart Problem? NO YES ……………………………… 9. Hearing or vision problems? NO YES ………………. Heart, Lungs 10. Eye glasses, contact lenses? NO YES ………………. Abdomen 11. Dentures or hearing aid? NO YES …………………. Extremities 12. Loses of function of a body part? NO YES ……………. 13. Require a special diet? NO YES Neurological …………………….. 14. Special psychiatric needs? NO YES ………………….. Hernia Check 15. High blood pressure, hypertension? NO YES …………. If the answer to any of the above questions is explain fully below. Give details as to when the event occurred, your current status, and any special needs that “yes”, child’s Allergies to Medicine: YES NO If yes, please list: he now has. Restrictions Name (print) Physician’s Address City/State/Zip Phone Medications: Signature Physician’s NAME EXACT DOSAGE SPECIFIC TIME GIVEN 1. Parent/Guardian (NAME): Phone: H ADDRESS: CITY B STATE ZIP (*Examination must not have been given more than 90 days prior to activity. Date(s) of activity is/are ) Emergency Contact if parent/guardian not available: Name: Address State Zip Phone H B Name Address State Zip Phone H B Family Doctor: Name Phone ADDRESS: CITY STATE ZIP Medical Insurance Policy Name Policy #
MEDICAL EXAMINATION Date of examination Applicant’s Date of Birth Height Weight Blood Pressure ABNORMAL COMMENTS Eyes Ears Nose,Throat Heart, Lungs Abdomen Extremities Neurological Hernia Check Allergies to Medicine: YES NO If yes, please list: Restrictions Physician’s Name (print) Address City/State/Zip Phone Physician’s Signature Parent/Guardian (NAME): Phone: H ADDRESS: CITY B STATE ZIP (*Examination must not have been given more than 90 days prior to activity. Date(s) of activity is/are ) Emergency Contact if parent/guardian not available: Name: Address State Zip Phone H B Name Address State Zip Phone H B Family Doctor: Name Phone ADDRESS: CITY STATE ZIP Medical Insurance Policy Name Policy # To be answered by parent or guardian (Check one) DOES YOUR CHID HAVE OR EVER HAD: 1. Sickle Cell Anemia? ………………………... NO YES 2. Food medication allergy? ………………….. NO YES 3. Epilepsy, seizures, fainting spells? …………. NO YES 4. Heat Stroke or heat exhaustion? ……………. NO YES 5. Diabetes mellitus (sugar)? …………………. NO YES 6. Hemophilia (bleeding disorder)? ……………. NO YES 7. Bone or joint problem? …………………….. NO YES 8. Heart Problem? ……………………………… NO YES 9. Hearing or vision problems? ………………. NO YES 10. Eye glasses, contact lenses? ………………. NO YES 11. Dentures or hearing aid? …………………. NO YES 12. Loses of function of a body part? ……………. NO YES 13. Require a special diet? …………………….. NO YES 14. Special psychiatric needs? ………………….. NO YES 15. High blood pressure, hypertension? …………. NO YES If the answer to any of the above questions is “yes”, explain fully below. Give details as to when the event occurred, your child’s current status, and any special needs that he now has. Medications: NAME EXACT DOSAGE SPECIFIC TIME GIVEN 1.
Form-9A-Application-for-Membership-Revised-Jan-2016.docx