Health History, Emergency Contact Information Permission To Treat With First Aid And Medical Authorization Page 2
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2Health History, Emergency Contact Information
Permission to Treat with First Aid and Medical Authorization
295 Busch Blvd
Columbus, OH 43229
614 888-8393
6
Health History (check. Please explain any check marks. )
____________ Frequent Ear Infections _______________________________________________________________________________________________________________
____________ Frequent Headaches ____________________________________________________________________________________________________________________
____________ Heart Defect/Disease __________________________________________________________________________________________________________________
____________ Convulsions _________________________________________________________________________________________________________________________________
____________ Seizures _______________________________________________________________________________________________________________________________________
____________ Diabetes ______________________________________________________________________________________________________________________________________
____________ Bleeding/Clotting Disorders ________________________________________________________________________________________________________
____________ Hypertension _______________________________________________________________________________________________________________________________
____________ Musculoskeletal Disorders ___________________________________________________________________________________________________________
____________ Other (specify) ____________________________________________________________________________________________________________________________
Allergies (Specify allergic reaction and management of the reaction)
____________ Animals (Animal and reaction) _____________________________________________________________________________________________________
_____________ Hay Fever ___________________________________________________________________________________________________________________________________
____________ Posion Ivy ___________________________________________________________________________________________________________________________________
____________ Insect Stings (insect and reaction) _______________________________________________________________________________________________
____________ Does your child have an Epi Pen and know how to use it? ___________________________________________________________
____________ Penicillin ______________________________________________________________________________________________________________________________________
____________ Other Medication/Drugs _____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________
____________ Asthma _________________________________________________________________________________________________________________________________________
_____________ Food (Item and reaction) ____________________________________________________________________________________________________________
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