Health Information Form
Email address *
Information provided is confidential and will only be used in case of an emergency. Thanks, Group Doctor: Michael Austin
Demographics
Last Name *
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First Name *
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Middle Name(s)
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Gender *
Date of Birth *
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Address - Street *
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City *
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Postal Code *
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Home Phone number *
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Cell phone number
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Emergency Contact
Name of Emergency Contact (plus relationship to singer) *
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Emergency Contact Phone Number *
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Medications
Medications (if yes, list below Medication/Dose/Frequency) *
Medications (Dose/Frequency)
Your answer
Medications (Dose/Frequency)
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Any history of Anaphylaxsis *
Medications (Dose/Frequency)
Your answer
Medications (Dose/Frequency)
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Medications (Dose/Frequency)
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Allergies
If history of Anaphylaxsis please list agent(s)
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Medication Allergies (if Yes list Medication and reaction) *
Medication and reaction
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Medication and reaction
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Other Allergy and reaction
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Medication and reaction
Your answer
Medication and reaction
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Other Allergies (if Yes allergy and reaction) *
Other Allergy and reaction
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Other Allergy and reaction
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Medical History
Medical Conditions (please check all appropriate)
Please describe Genetic Condition
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Any additional Medical Hx not above?
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Does your child have any physical limitations? *
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