American Nanny Company - Medical Information Letter

Medical Information Letter for American Nanny Company Applicants

How would you rate your overall health? ___ Excellent ___ Good ___ Fair ___ Poor

What is your Height? __________ Weight? __________

When was your most recent medical check-up? ______________________________

Now or in the past, have you consulted a physician for any of the following:

	Yes	No	If Yes, Please Explain
1. Regular use of any prescribed drug
2. Fainting spells or dizziness
3. Allergies or asthma
4. Frequent colds or flu
5. Anemia, mononucleosis or hepatitis
6. Anorexia nervosa and/or bulimia
7. Backaches, back or neck injuries
8. Depression, nervous conditions or other mental disorders
9. Venereal Disease or A.I.D.S.
10. Alcoholism or drug dependency
11. Diabetes
12. Skin rashes or other skin problems
13. Any disabilities which would interfere with your capacity to perform certain activities or duties

My physician is:

Do we have your permission to contact your physician/hospital, if necessary? ___Yes ___No

Signature: _______________________

If you have any questions please call us at 1-800-262-8771.

INSTRUCTIONS:
Please print this form, fill it out and send it back to the American Nanny Company using one of the following methods:

U.S. Mail: American Nanny Company or Fax: 1-617-969-1269

PO BOX 765 Newtonville Branch

Boston, MA 02460

Autobiographical Letter | Medical Information Form | Medical Examination Form
Information Verification Release (Graham/Sheehan) | Return to Forms Index

U.S. Mail:	American Nanny Company	or	Fax:	1-617-969-1269
	PO BOX 765 Newtonville Branch
	Boston, MA 02460