Health Questionnaire

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Sep 08

Wednesday

Up Coming Events:

Fall 2010 Semester (click here for Calendar)

Classes have Begun!

Health Questionnaire

Are you in good health?

When was your last complete physical examination:

List any major illnesses you have had:

Do you have any physical handicaps?

If yes, please explain:

Do you have any communicable diseases?

If yes, please explain:

Are you taking any prescription drugs?

If yes, please list what you are taking:

Please place a check beside any known medical conditions and explain in the space provided below. Allergy - Bee Sting
Allergy - Food
Allergy - Medications
Asthma
Asthma - On Medication(s)
Blood Disorder
Cancer/Leukemia
Cerebral Palsy
Color Blindness
Diabetic
Eating Disorder
Epilepsy/Seizures
Glasses/Contact Lenses
Heart Problems
Hearing Aid used
Hearing Loss
Partially sighted
Speech problems
Other
No Known Health Problems

Details & Explanations:

Are you currently on medication or under a physicians care for physical issues?

If yes, please give details:

Physician’s Name:

City:

State:

Zip:

Phone #

Fax #

Medication(s):

Have you been hospitalized or admitted to a treatment facility for any reason?

If yes, please explain including dates:

Have you been, or are you presently dealing with an eating disorder?

If yes, please explain including dates:

Have you been, or are you presently under psychiatric or psychological care?

If yes, please explain including dates:

Are you under a doctor’s care for either mental or emotional issues?

Type of doctor:

Doctor's Name:

City:

State:

Zip:

Phone #:

Fax #:

Medication(s):

Type the characters you see in the picture below

Physical Address: 27862 County Road 12, Somerset, CO 81434 - Student Address: P.O. Box 555, Somerset, CO 81434

E-Mail: jeffchristianson@calvarychapel.com - Web: www.CCBCcolorado.com - Phone: (970) 929-5221 - Fax: (970) 929-5322

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