CYIA Medical Questionnaire

Name

Age

Today's date

Medical Coverage for Applicant

Note: CYIA students are covered by accident insurance while at the CYIA training school.

Name of insurance company

Policy number

Date of last tetanus shot

Is the applicant subject to:

Asthma

Yes No

Hay Fever

Yes No

Epilepsy

Yes No

Food Allergies

Yes No

If yes, please list:

Allergies to Medications

Yes No

If yes, please list:

Other Allergies (flowers, grass, etc.)

Yes No

If yes, please list:

Has the applicant had:

Chicken Pox

Yes No

Rheumatic Fever

Yes No

Mumps

Yes No

Rubella (German Measles)

Yes No

Measles

Yes No

Serious reaction to bee sting

Yes No

Does the applicant have:

Diabetes

Yes No

Hypoglycemia

Yes No

Is the applicant on a special diet?

Yes No

If so, what is it?

Has the applicant had any illness requiring a visit to the doctor or hospital in the last three months?

Yes No

If so, what was the health problem?

The nurse carries the following stock items. Please mark any you DO NOT want your child to receive. Asprin Aleve Ibuprofen Tylenol Tums Pepto-Bismol Throat lozenges (for sore throats and cough)

Allergy relief: Decongestants Cold syrups Loratadine Zyrtec Benadryl

Skin ointments: Neosporin Hydrocortisone Calamine Sunscreen Insect repellent

Please send prescription drugs in original container with proper dosage and usage inscribed. Mark student's name with permanent pen on all inhalers.

Please list any prescription drugs being brought by the applicant: (Name of medication, what it is for, and dosage and directions)

Note: If applicant has serious reactions to food or insect bites that require an Epi-Pen, please send with your student.

I understand that if the applicant is sick over 36 hours, I will have to arrange for other transportation home. In case of medical emergency, I hereby give permission to the physician selected by the training school nurse to secure proper treatment for me or my child as named on this form. (You will be notified as soon as possible in case of serious injury or illness.)

Note: On electronic forms, your typed signature carries the same weight as your written signature.

Signature of applicant or parent/guardian (if applicant is under 18)

Phone

Address

If unable to notify me in case of emergency, please contact:

Name

Relationship to applicant

Emergency contact phone

CYIA Medical Questionnaire - Capital

Description

CYIA Medical Questionnaire - Capital

Description

Please Fix the Following