LOCAL INTAKE ASSESSMENT - Section 6 - Medical Risk Factors

Local Full Name

First Name

Last Name

Local Health Rating

Serious Health Conditions

I.e. heart failure, diabetes, CP, etc. If none, type "none."

History of stroke or heart attack

Any medical contains that require assistance

Reaction to Anesthesia

Major Allergies

Are vaccinations up to date?

Yes

Unvaccinated

History of Seizures/Date of last seizure

Is Local able to self-report illness or injury?

Is Local able to make their own appointments?

Family History of Major Illness

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