High School Exchange Student Medical Form
Student Information
Full Name
Date of Birth
Gender
Female
Male
Other
Nationality
Emergency Contact
Contact Name
Relationship
Phone
Email
Medical History
Allergies
Current Medications
Chronic/Serious Health Conditions
Past Surgeries or Hospitalizations
Immunizations
List of Immunizations (with dates)
Physician Information
Physician Name
Physician Phone
Physician Address
Insurance
Insurance Company
Policy Number
Insurance Phone
Authorization
Parent/Guardian Authorization & Signature
Date