Glion Medical History printable pdf download

TO BE FILLED IN BY THE APPLICANT

PLEASE SEND THIS FORM TO:

Glion Institute of Higher Education

Name ��

Admissions Department

Rue du Lac 118 - 4

floor

Male

Female

Date of Birth: Day �� Month�� Year ��

CH-1815 Clarens - Switzerland

Phone:

+41 (0)21 989 26 00

Name of the Parent/Guardian ��

Fax:

+41 (0)21 989 26 78

E-mail:

admissions@glion.edu

Address ��

Website:

City �� Postal Code ��

State �� Country ��

Home Phone �� Mobile Phone ��

Fax �� Email ��

PERSONAL HISTORY

Did you ever have or do you suffer from (if yes, please indicate when; and in case of vaccination, indicate the date):

Yes No (if yes, when)

Chicken Pox

��

Diabetes

��

Mumps

��

Rubella

��

Tuberculosis

��

Measles

��

Hepatitis A/B/C

��

Any neurological condition:

��

(eg. Epilepsy, head injuries, etc.)

Any mental condition (psychological/psychiatrical):

��

(eg. depression, bipolar disorder, eating disorders, etc.)

Any learning difficulties:

��

(e.g. dyslexia, dyscalculia, ADHD, ADD, etc.)

Accident/disorder with physical long term consequences:

��

Allergies to medicine or any other products:

��

For the following points, please specify if you:

Have had any other disease or have had an operation recently: ��

Take any medication on a regular bases: ��

Are on a special diet:��

With regards to any of the above special needs or medical condition you may have, GIHE aims to create an environment which enables

all students to participate fully in the campus life. To help us make reasonable adjustments, it is imperative to clearly indicate your medical

condition and/or special needs (ie. dyslexia). Please note that consideration of how we can meet any special needs is separate to the

assessment of your academic suitability.

How would you describe your general health condition?

Excellent

Very Good

Good

Poor

In keeping with the institute’s policies regarding preventive health measures, the Campus Management may request a student to undergo a

medical checkup or mental health assessment at any time during her/his studies at GIHE.

I hereby certify that the above information is correct and that I agree to undergo a medical checkup or mental health assessment if required.

Deliberate false statements may result in expulsion. GIHE will not be held responsible in case of incorrect medical information stipulated on

the medical certificate and physician’s report.

We reserve the right to withdraw a student from GIHE if we deem our internal health care support services are unable to meet the need of

the student concerned or if the student does not follow external medical advice and/or guidelines.

Date & Signature of the Student:

Date and Signature of the Parent/Legal Guardian:

��

Glion Medical History

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