Here's a nice .pdf one to print that also contains a hand-out for the physician:
http://www.2ampd.net/Articles/horn2/Firearms%20Malpractice%20Form.pdf
I haven't read the whole thing, but from what I can tell, it's ridiculous. Might as well ask about car seats, hammers, scissors, electrical outlets, floor cleaners, Drano, aspirin, baby oil, vitamin supplements, air fresheners, chain saws, drills, oh yeah... and swimming pools, staircases, windows, bicycles (w/ or w/o training wheels), salt, sugar soaked cereal, ... well, you get the point.
But after all, just because someone asks a question doesn't mean I'm required to answer it.