Medical Information Form: Ohio
Please provide the following information so that we ensure each participant is safe and understood at Ohio Miss Amazing.
First Name *
Your answer
Last Name *
Your answer
Attending Physician *
Your answer
Physician's address *
Street
Your answer
*
City
Your answer
*
State
Your answer
Medical condition
Any condition in addition to the diagnosis that may affect abilities. Ex. heart disease, diabetes, asthma, etc.
Your answer
Current Medications
Your answer
Allergies and/ or drug sensitivities
Your answer
Equipment
Does the participant need assistance walking? *
Does the participant have seizures? *
If yes, type/ length/ frequency
Your answer
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