Participant Health Form
Name: ________________________________________________________________________________________
Last First Middle
Permanent Address: _____________________________________________________________________________
___________________________________________________________________________
Home Phone: _______________________ Social Security # ____________________________
Parent/Guardian: ____________________ Daytime Phone: _________________ Eve. Phone __________________
Parent/Guardian: ____________________ Daytime Phone: _________________ Eve. Phone __________________
If my parent is not available in an emergency, notify:
____________________________________ Phone: __________________________ Phone: __________________
____________________________________ Phone: __________________________ Phone: __________________
Health History: (Check - giving approximate dates)
Diseases/Illnesses:
ÿAsthma __________ ÿGerman Measles __________ ÿMono ___________
ÿBleeding Disorder __________ ÿHeart Problems __________ ÿMumps ___________
ÿCancer __________ ÿHigh Blood Pressure __________ ÿRecurring Strep Inf. ___________
ÿChicken Pox __________ ÿ Hypoglycemia __________ ÿRespiratory Problems ___________
ÿDiabetes __________ ÿKidney Problems __________ ÿRespiratory Problems ___________
ÿEar Infections __________ ÿKnee Problems __________
ÿEating Disorders __________ ÿMeasles __________
Allergies: Drug Allergies: (List any medication you are allergic to)
ÿHay Fever __________ _________________________________________________________
ÿInsect Stings __________ _________________________________________________________
ÿIvy Poisoning __________ _________________________________________________________
ÿOther __________ ____________________________________________________
Have you been out of the USA in the past 9 months? ______ If so, where? _________________________________
Immunizations:
ÿTetanus – Date of Last Tetanus: _______________ (Obtain Tetanus if you are not current)
Have you been (in the past 12 months) or are you currently being treated for a psychiatric/psychological disorder? ________
If yes, please explain: __________________________________________________________________________________
List any previous surgeries or injuries (Give Dates): __________________________________________________________
____________________________________________________________________________________________________
Any illness occurring within the last 5 years that caused you to miss school or work for mare than 3 days:
____________________________________________________________________________________________________
I am covered under my parents’ Medical Insurance Plan: ___Yes ___ No
If so, name of Insurance Company: _______________________________________________________________________
I have Medical Insurance of my own: ___Yes ___ No
If so, name of Insurance Company: _______________________________________________________________________
Insurance Policy #: _____________________________ Insurance Policy Phone #: ________________________________
Consent for Treatment
I hereby give permission to the physician selected by the SOS Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for myself. (Guardian signature required if under 18 years of age).
