MedicalHistory2010

NATIONAL INDIAN YOUTH LEADERSHIP PROJECT CONFIDENTIAL MEDICAL HISTORY

INSTRUCTIONS: Complete all parts of this form, front and back. Parent’s signature is required if participant is under 18 years old.

NOTE: Full disclosure of your current health is required for participation.

GENERAL INFORMATION

Name: ______

Home Address: ______

(Street) (City) (State) (Zip)

Home Phone: ______Date of Birth: ____ /____ /____ Census #: ______

Male Female Age: ______SS#: ______

Family Physician Name: ______Phone: ______

EMERGENCY CONTACT INFORMATION (In the event of an emergency, who do we contact):

Parent’s Name: ______

Phone (Day): ______(Night): ______

2nd contact’s Name: ______Relationship: ______

Phone (Day): ______(Night): ______

INSURANCE INFORMATION AND/OR HOSPITAL INFORMATION

Insurance Company Name: ______Policy #: ______

IHS Facility – Chart Number: ______

HEALTH HISTORY

Height: ______Weight: ______Do you wear glasses? ____ Yes ____ No.

Do you wear contacts? ____ Yes ____ No

Are you under the care of a physician? ____ Yes ____ No If yes, Please Explain: ______

Are you currently taking medication? ____ Yes ____ No If yes, please list and explain: ______

______

Do you have asthma? ____ Yes ____ No If yes, bring your inhaler along.

Do you have any disabilities? ____ Yes ____ No If yes, please explain: ______

______

Do you have any recent injuries, illnesses or operations? ____ Yes ____ No If yes, please explain: ______

HEALTH HISTORY continued

Do you have diabetes, seizures or frequent fainting/dizziness? ____ Yes ____ No If yes please explain:

______

Do you have any back, neck or spine injury/pain? ____ Yes ____ No If yes, please explain: ______

______

Do you have migraines or suffer from headaches? ____ Yes ____ No If yes, please explain: ______

______

Do you have a history of heart problems? ____ Yes ____ No if yes, please explain: ______

______

Are you pregnant? ____ Yes ____ No

If yes, you can not actively participate without written permission from your physician?

Individuals suffering from Musco-skeletal injuries or cardiovascular illness will not be permitted to participate in certain activities without written permission from their physician.

Please state the type of physical condition are in: ____ Athletic _____ Good _____ Fair _____ Poor

ALLERGIES: (please check all that apply. Bring your epi-pen or other medications along.

Poison Ivy Bee stings Other insect stings/bites Penicillin Aspirin

Foods (please list) ______

Other (please explain) ______

Please list. Include allergies to medication: ______

IMMUNIZATIONS: (give date of latest inoculation or booster)

______D.T.P Series ______Tetanus Booster ______Polio Series ______Smallpox ______Measles ______Rubella ______Tuberculosis Test, result: ____ Pos ____ Neg

Please indicate any other health information we should know to provide you with a safe experience such as special diet requirements, physical activity restrictions, etc…______

______

I certify that the information provided above is a complete and accurate statement of the physical factors which may affect my participation in a National Indian Youth Leadership Project program. I realize that failure to disclose such information could result in harm to myself or my fellow participants. I agree to Indemnify and hold the National Indian Youth Leadership Project, its staff and contractors harmless.

Participants Signature: ______Date: ______

Parent/Guardian Signature if under 18 years old: ______Date: ______

1

Revised 04.5.10