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S.C.O.T. LTD. Medical Form 2008
Name:         Age:          
          Birth date:        
I. What are your Allergies?  
Allergy to any medication?              
                     
Allergy to anything (bee stings, foods, etc.)          
                     
II. Do you have, or have you ever had?  
Diabetes?   Seizures?            
Any Surgery?   Date:    
Describe:                  
Any Precautions or Limitations?              
Recent Injuries? (within the past 6 months/ongoing or not)      
Describe injury:               Date:  
Describe Circumstance:              
Have you seen a doctor for this condition?   Who?        
Describe its present condition?              
   
                     
III. Do you wear or use?  
Contact Lenses?    
Braces, supports, air splints, etc.?   Describe:        
             
Where?         Reason:        
                     
IV. Date of last tetnus shot (update every 5-10 years)      
V. Are you currently taking any?  
Prescription Medications?   Describe:        
Reason:          
                     
ANY medicines?   Describe:  
             
VI. Medical Insurance Information:  
Issuer Name & Address:     Policy Number:        
     
          Telephone:        
Primary Health Care Provider - Name & telephone Number:  
                     
                     
VII. Is there anything else our staff should know?  
                     
   
                     
VIII. Parent(s) Name & Complete address: Emergency Contact Address:  
(Please complete in detail)   Write same, if same as parents:  
(We must have this information)        
Parents:      
       
       
       
Home Phone:         Home Phone:      
Work Phone:         Work Phone:      
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