Student Medical Form Nyc Minority Program (Page 3 of 4) in pdf

Are you allergic to anything?_______________________Please list: _________________________________________

_________________________________________________________________________________________________

(please a separate sheet of paper, if necessary)

In particular, are you allergic to bee stings? ______________________________________________________________

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

_________________________________________________________________________________________________

Do you carry an anaphylaxis kit? ______________________________________________________________________

ILLNESSES AND MEDICATIONS

List any recent illnesses: _____________________________________________________________________________

_________________________________________________________________________________________________

List any accidents, operations, or hospitalizations and dates occurred: ________________________________________

_________________________________________________________________________________________________

List any exposure to infectious diseases and dates occurred: ________________________________________________

_________________________________________________________________________________________________

Have you ever experienced any conditions or illness related to altitude? ______________________________________

If so, please explain, and tell us when:_ _________________________________________________________________

_________________________________________________________________________________________________

Please describe any medications you are taking, why you are taking them, how much and how often: ___________________

_________________________________________________________________________________________________

Student Medical Form Nyc Minority Program Page 3