Medical History Form Medical HistoryStudent Name *Date of Birth *Medical HistoryAllergies *List all allergies (medications, food, insects etc.) and the reactions.Do you smoke or use any tobacco products? YesDo you drink alcohol? YesMedical Conditions Please check any conditions that you have been or are currently being treated for:ADHDAlcohol/Drug DependencyAmbulatory ImpairmentAnemia, Blood DiseaseAnxiety/DepressionArthritis, Joint/Bone DiseaseAsperger SyndromeAsthmaAutismBack/Neck Pain/ConditionBipolar DisorderBlood Clots, PhlebitisCancerChicken PoxCrohn's DiseaseDiabetes Type 1Diabetes Type 2Digestive DisorderEpilepsy, SeizuresFainting SpellsHead InjuryHearing ImpairmentHeart Murmur, DiseaseHemophiliaHepatitisHigh Blood PressureHypoglycemia (Low blood sugar)Kidney DiseaseLow Blood PressureLyme DiseaseMalariaMigrainesPsychiatric ConditionsRheumatic FeverSickle Cell DiseaseSchizophreniaThyroid DiseaseTuberculosisUlcerative ColitisVisual ImpairmentOther medical conditions List any other medical condition you have that is not on this list.Doctor InformationDoctor’s Name *Office Phone Number *Specialty Doctor’s Name Office Phone Number Specialty Current MedicationsMedications List *Please list all medications taken by the student and the frequency with which they are taken. VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
