College Of William And Mary Student Health Evaluation Form Page 6
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7THE COLLEGE OF WILLIAM AND MARY
STUDENT HEALTH CENTER
P. O. Box 8795
Williamsburg, VA 23187-8795
Phone (757) 221-4386 / fax (757) 221-1245
E-mail:
sthlth@wm.edu
AIR CONDITIONER MEDICAL NECESSITY FORM
The Student Health Center physicians have been asked to screen all students requesting approval for
air conditioners. The wiring system in some of the older residence halls is such that they can only handle a
limited amount of additional load from air conditioners. For that reason, we need to carefully screen all air
conditioner requests to ensure that those students who have true medical problems that would clearly be
worsened without air conditioning are able to have air conditioners in their rooms. If you feel your patient
meets these criteria, please provide the information below. Please understand the final decision will be
made by one of our Health Center physicians. We appreciate your taking the time to provide this
information so we can make the appropriate decision.
st
This form needs to be completed and returned by July 1
for those entering the Fall Semester and January
10th for those entering the Spring Semester.
You will not be approved for air conditioning until your Health Evaluation Form is complete.
Last Name
First Name
Middle Name
Date of Birth
Student ID #
Diagnosis: _________________________________________________________________________________________________
Current Medicines being used to address the above diagnosis: ____________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
If Allergic Rhinitis is the diagnosis, please list (or enclose) results of skin testing, if done: _______________________________
__________________________________________________________________________________________________________
Comments: ________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
____________________________________________________________
____________________________________________________________
PRACTITIONER NAME/TITLE(M.D., N.P., R.N., P.A.)
*SIGNATURE
PLEASE NOTE!
Students will not be approved for an air conditioner (if they meet the criteria) until the Student Health Center Staff is
in receipt of their COMPLETED Health Evaluation Form.
Release of Information
I give my consent to allow a Release of Medical Information regarding the medical condition for which I am seeking an Air
Conditioner or Special Housing to the Dean of Students and Residence Life at the College of William and Mary.
Signature
Date
If you are under 18, a parent or guardian must also sign form:
Signature
Relationship
Date
Student Health Center
College of William and Mary 230 Gooch Dr. P.O. Box 8795 Williamsburg, VA 23187-8795 (757) 221-4386
Email:
sthlth@wm.edu
Revised 3/2016
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