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STUDENT NAME M or F AGE / DOB / GRADE HOME ADDRESS STREET CITY OPCODE EMERGENCY CONTACT FIRST CONTACT (NAME) RELATION HOME PHONE MOLLIE PHONE WORK PHONE SECOND CONTACT (NAME) RELATION HOME PHONE MOLLIE
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How to fill out the Phys FormRev 1110:

01
Start by reviewing the form thoroughly. Familiarize yourself with all the sections and fields that need to be completed.
02
Gather all the necessary information and documents required to fill out the form. This may include personal details, medical history, and any supporting documentation.
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Begin by providing your personal information, such as your full name, address, date of birth, and contact details. Ensure that you provide accurate and up-to-date information.
04
Move on to the medical history section. Provide details about any previous illnesses, surgeries, or ongoing medical conditions. Be as thorough and accurate as possible to aid the assessment process.
05
If applicable, include information about any medications you are currently taking. Include the name, dosage, and frequency of each medication.
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Ensure that you answer all the questions on the form, especially those marked as mandatory. If you are unsure about any particular question, seek clarification or assistance from a healthcare professional.
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If you require additional space to provide any extra information or explanations, make use of the provided space for comments or attach additional sheets if needed.
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Carefully review the completed form for any errors or omissions before submitting it. Double-check all the information provided to ensure its accuracy.
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Sign and date the form as required. Some forms may require additional signatures, such as a witness or a healthcare professional.
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Keep a copy of the filled-out form for your records, especially if it is to be submitted to a third party (such as an employer or medical institution).

Who needs the Phys FormRev 1110?

01
Individuals applying for certain occupations: The Phys FormRev 1110 may be required as part of the application process for certain occupations that involve physical demands or potential health risks. Employers may need this information to evaluate an individual's suitability for the position.
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Students joining sports teams or participating in physical activities: Schools or universities may require the completion of the Phys FormRev 1110 to assess the student's physical fitness and ensure their safety during sports or physical activities.
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Medical institutions and healthcare providers: Physicians or healthcare providers may require individuals to fill out the Phys FormRev 1110 to obtain a comprehensive medical history and assess their overall health status. This information is crucial in providing appropriate medical care and making informed decisions about treatment options.
Note: The specific requirements for the Phys FormRev 1110 may vary depending on the purpose and requesting party. It is always advisable to carefully read the instructions provided with the form and seek guidance if needed.
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