Read MEDICAL HISTORY text version

Evolved Workouts, LLC Medical History Form ­ Child

Child's Name:_______________________________________________________________________ Date:_________________

First Name MI Last Name

Legal Guardian's Name:____________________________________________________________________________________

First Name MI Last Name

Guardian's Relationship to Child:__________________________________Best Contact #:__________________________ Child's Address:____________________________________________________________________________________________

Street Apt# City State Zip

Child's Age:__________ Child's Sex:__________ Child's Weight in lbs:______________ Child's Height:_____________

MEDICAL HISTORY Please list any prescribed medications your child is currently taking (name and reason). _______________________________ _______________________________ _______________________________ _______________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

List any over the counter medications your child is currently taking (name and reason). _______________________________ _______________________________ _______________________________ _______________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

List any dietary supplements your child is currently taking. __________________________________________________________________________________________ List any illness, hospitalization, or surgical procedure(s) within the past two years. __________________________________________________________________________________________ Please list any drug allergies. __________________________________________________________________________________________

Please list date last of last physical examination and results. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Is your child currently under a doctor's care? If so why? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Does your child currently have any medical conditions for which your doctor has recommended some restrictions on activities (including surgery)? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Has anyone in your immediate family (yourself, other parent, father, mother, brother, or sister) had a heart attack, stroke, or other heart-related problems? __________________________________________________________________________________________ __________________________________________________________________________________________

All of the questions above have been answered completely and truthfully to the best of my knowledge.

Guardian's Signature:_________________________________________________ date:_______________________________

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MEDICAL HISTORY

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