My Health Name * First Name Last Name Age * Parent name * First Name Last Name Parent phone number * Emergency contact * First Name Last Name Emergency contact phone number * I take medication (prescribed and/or non prescribed) * Yes - daily Yes - sometimes No I take supplements * Yes - daily Yes - sometimes No I have allergies * Yes - daily Yes - sometimes No List any allergies to Food/Medication/Plants/Animals/Masks/Other * Thanks for taking the time to complete this form.We will be in touch with you shortly.
