Volunteer Dss Medical Histroy Form - Boys And Girls Homes printable pdf download

Volunteer Dss Medical Histroy Form - Boys And Girls Homes

MEDICAL HISTORY FORM

NORTH CAROLINA DIVISION OF SOCIAL SERVICES

Name: ___________________________________________________________________________________

Home Address: ____________________________________________________________________________

Phone: ______________________________________ Date of Birth: _________________________________

HEALTH HISTORY

Any history, past, or present of:

YES

Head or back injuries

Neurological disorders, convulsions, etc.

Heart disease, high blood pressure, or rheumatic fever

Lung disorders, asthma, tuberculosis

Stomach, gall bladder, or other gastro-intestinal disorders

Allergies to food, drugs, plants, etc.

Blood disorders, anemia, leukemia, etc.

Kidney trouble

Venereal disease

Diabetes or other glandular disorders

Surgery

Physical disabilities

Psychological disorders, mental health diagnosis, drug/substance abuse

Other chronic illnesses, diseases, or disorders

If any of the above questions were answered yes, provide explanation:

_________________________________________________________________________________________

Excellent 

Good 

Fair 

Poor 

What do you consider your state of health:

To the best of my knowledge, the above information is correct.

______________________________________________________________ __________________________

Signature

Date

DSS-5017 (rev. 04/11)

Please return to: Boys & Girls Homes of N.C., Inc.

Child Welfare Services

Tesa Bush, HR

P.O. Box 127

400 Flemington Drive

Lake Waccamaw, NC 28450

Volunteer Dss Medical Histroy Form - Boys And Girls Homes