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Other Medical information
Please indicate any of the following which apply
Allergies (non life-threatening)
Yes
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(Required)
Arthritis
Yes
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(Required)
Cardiac Conditions
Yes
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Chokes Easily
Yes
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Circulatory Problems
Yes
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Dentures
Yes
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Diabetic
Yes
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(Required)
Epilepsy
Yes
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Fear (water, animals, etc.)
Yes
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(Required)
Hearing Loss
Yes
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(Required)
Hepatitis B Carrier
Yes
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(Required)
IBS
Yes
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(Required)
Psychiatric Illness
Yes
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(Required)
Respiratory Problems
Yes
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(Required)
Seizures
Yes
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(Required)
Special Diet
Yes
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(Required)
Stomach Problems
Yes
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Wears Glasses or Contacts
Yes
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Wears Braces/Special Shoes
Yes
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(Required)
Uses Alternative Communication
Yes
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(Required)
Participant Diagnosis
Please provide a detailed description and any other information that would help us understand your participant's needs.