Medical Information (Strictly Confidential)

 

Name: ________________________

Address: ______________________________________________________

Are you at present under medication ______ If yes, please specify:

______________________________________________________________

______________________________________________________________

Have you ever had surgery? _____ If yes, please specify:

______________________________________________________________

______________________________________________________________

______________________________________________________________

Have you ever consulted or been treated by a psychologist, psychiatrist,

social worker or counselor? ________ If yes, please specify (including any

medication you may have received for the above mentioned):

______________________________________________________________

______________________________________________________________

______________________________________________________________

Do you have special dietary needs? ______ if yes, please describe:

______________________________________________________________

______________________________________________________________

______________________________________________________________

Do you suffer from allergies? ______ if yes, please describe:

______________________________________________________________

______________________________________________________________

______________________________________________________________

Do you need to take any medical precautions? _____ if yes, please describe:

______________________________________________________________

______________________________________________________________

______________________________________________________________

I Father / Mother of ________________________ authorize the Meorot Chabad to

receive any additional relevant medical information from

any medical authority.

I furthermore authorize the transfer of any additional relevant medical

information for the purpose of treating my son in case of illness while he is

residing in Israel.

Date: _____________ Signature: ________________