Directions For Completing Medical Requirement Forms (Page 4 of 8) in pdf

Directions For Completing Medical Requirement Forms Page 4

Personal Illness/Injury History:

Please list any previous accidents, injuries, illnesses, medical conditions or surgeries that you have had:

________________________________________________________________________________________________________

Healing Practices:

Do you participate in any traditional healing methods? If so, please describe:

________________________________________________________________________________________________________

Do your spiritual beliefs prevent you from seeking any type of medical treatment? If so, please

explain__________________________________________________________________________________________________

Certification and Agreement: Medical Information/History

I hereby certify that the above information I have given is correct and that I have no other conditions

that may affect my ability to fulfill my placement responsibilities. In addition to this, I am agreeing to

disclose any pertinent medical information in the event I become injured or develop an illness during

clinical placement or during class time that could be threatening to my life or the health of others.

Signature of Student: _________________________________ Date: ___________________________

Medical Form

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Directions For Completing Medical Requirement Forms Page 4