RVLA Freedom Clinic school nurse form 25/26
Required Field
Personal Info
First Name
Last Name
Are you currently enrolled in the Freedom Clinic?
Yes
No
Unsure
I would like:
a band-aid
a pad or tampon
ice pack
hot pack
medication my parent/guardian has left for me
to go home
other- please describe:
Characters:
0
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I have the following symptoms:
stomach hurts
headache or migraine
menstrual cramps
injury/wound- please list where?
Characters:
0
/255
pain- please list where your pain is
Characters:
0
/255
not feeling well/sick
Characters:
0
/255
other- please describe:
Characters:
0
/255
I would like to schedule:
a sports physical
a pregnancy test
STD/STI testing
an appt to discuss birth control
an acupuncture visit
a massage visit
a wellness visit or appt to discuss a health concern/question
other- please tell us more:
Characters:
0
/255
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