Student Medical Form Nyc Minority Program (Page 2 of 4) in pdf

City, State: ____________________________________________________ Zip Code: ___________________________

Home Phone: _____________________________________________________________________________________

Day/Work Phone: ____________________________ Cell Phone: ____________________________________________

Relationship to you: ________________________________________________________________________________

If the Above Person is Unavailable, please notify:

Name: ___________________________________________________________________________________________

Street Address: ____________________________________________________________________________________

City, State: ____________________________________________________ Zip Code: ___________________________

Home Phone: _____________________________________________________________________________________

Day/Work Phone: ____________________________ Cell Phone: ____________________________________________

Relationship to you: ________________________________________________________________________________

MEDICAL INSURANCE INFORMATION

We strongly encourage you to have medical insurance and to bring your insurance card or other documentation with you

to the Institute.

Insurance Carrier: __________________________________________________________________________________

Policy Number: ____________________________________________________________________________________

Contact Phone Number (if applicable): _________________________________________________________________

VITALS (You must provide all information—fill out every line—We mean it!)

Your date of birth: ________________________ Resting Pulse: __________________ Blood Pressure: ______________

Height: _________________________________ Weight: ______________________ Blood Type: _________________

EYES

Any problems with your eyes or vision? _________________________________________________________________

Do you wear glasses or contacts? _____________________________________________________________________

(If so, we strongly recommend bringing an extra set of glasses or contacts to the Institute.)

ALLERGIES

Have you ever had a reaction to any medication, including aspirin? __________________________________________

If so, how severe are your reactions? Please explain: ______________________________________________________

_________________________________________________________________________________________________

(Please use a separate sheet of paper, if necessary)

Student Medical Form Nyc Minority Program Page 2