Leadership Lehigh 2008

Confidential Health Form

Personal Health and Medical History

Please print in ink.

Name _______________________________________________________________________________

Spouse or Significant Other: _____________________________________________________________

Date of birth: ________________ Age: _____ Sex: ___

Home Address: ________________________________________________________________________

Work Address: ________________________________________________________________________

Phone: ______________________________________________________________________________

In case of an emergency, notify: __________________________________________________________

Address: ______________________________________________ Phone: _______________________

Name of personal physician: _____________________________________________________________

Phone: ______________________________________________________________________________

Check all that apply, past or present, to your health history.

Explain any “YES” answers. Circle answer.

Allergies: Food, medicines, insects, plants: Yes No

Explain: ______________________________________________________________________________

General Information: Asthma/Lung Disease: Yes No Cancer/Leukemia: Yes No

Convulsions/Seizures: Yes No Diabetes: Yes No Heart Disease: Yes No

Hemophilia: Yes No High Blood Pressure: Yes No Kidney Disease: Yes No

Explain: _______________________________________________________________________________

_____________________________________________________________________________________

Please list ALL medications: ______________________________________________________________

_____________________________________________________________________________________

List any special needs on back - dietary, medical equipment, etc.