Medical Information Form - Clarksville Theological Seminary printable pdf download

MEDICAL INFORMATION FORM

On-Campus Students only

MEDICAL INFORMATION

Name of Insurance Company: ___________________________________________________________________

MEDICAL INSURANCE IS NOT MANDATORY, BUT HIGHLY RECOMMENDED

Mailing Address: ____________________________________________________________________________

City: _________________________________ State: _____________

Zip: _________________

Policy or Group Number: ______________________________________________________________________

Identification Number: ___________________________________________________________________

Family Physician: ________________________ Telephone: __________________________

What is your height? _________________ and your weight? ____________________

If you check any of the boxes below, please include a brief explanation on a separate sheet.

Check all that apply:



 I have physical, mental or psychological limitations which may require some adjustments to a typical student

activity schedule.

 I am currently taking medication prescribed by a physician.

 I have been hospitalized in the past two years.

Immunization record (please list month and year)

Diphtheria/Tetanus ____/____ Measles 1

____/____ Measles 2

____/____ Rubella ____/____

Tuberculosis (within last 6 months) ____/____ Results: ________

Received childhood immunizations, but no longer have documentation.

Hospitalizations – include diagnosis and dates: _______________________________________________________________

_____________________________________________________________________________________________________

Surgeries – include type of operations and dates: _____________________________________________________________

_____________________________________________________________________________________________________

List any allergies: ______________________________________________________________________________________

List present medication, doses, and reason for taking: __________________________________________________________

List any physical limitations: _____________________________________________________________________________

List any known learning disability: ________________________________________________________________________

Clarksville Theological College & Seminary – Medical Information

Medical Information Form - Clarksville Theological Seminary