Medical History Form

1. Do you have any medical or psychological conditions that could interfere with your ability to safely work with children? *

2. Do you have any of the following medical conditions? Check all that apply.*

3. Currently, are you following medically advised or prescribed work restrictions? *

4. Currently, is your employer making modifications to your job duties to meet your medical needs?*

5. Currently, do you have a mental health condition that impairs your ability to safely care for children?*

6. I agree to immediately consult a doctor if I experience any physical or mental health issues that could affect my ability to safely care for children.*

7. I understand that if I have disclosed any medical conditions of concern, I must be available for a phone call during my scheduled appointment time.*