Health Information Form

ASHLAND UNIVERSITY | OFFICE OF CHRISTIAN MINISTRY

The purpose of this form is to provide important health information to Office of Christian Ministry in order to assist you should the need arise during any activities we sponsor. The information provided will remain confidential and will be shared with program staff, faculty or appropriate professionals only if pertinent to your own well-being. Office of Christian Ministry may not be able to accomodate all individual needs or circumstances. If more room is needed to answer the questions below, please use the space provided at the bottom of the page.

Office of Christian Ministry | 401 College Avenue, Ashland, OH 44805 | 419.289.5489 | (f) 419.207.6345

Student Name:*
Birth Date:*
  MM DD YYYY
/ /
Student ID Number:*
Gender:*
Program:*
Emergency Contact Information*
Name:
Relationship:
Phone No.:
Term:*
MEDICAL HISTORY

1. Are you generally in good physical condition? *
If no, please explain:
2. Have you ever been treated or are you currently receiving counseling for psychological or mental conditions (emotional problems, eating disorders, drug/alcohol, etc...)?*
If yes, please explain:
3. Do you have any allergies?*
If yes, please explain:
4. Are you taking any medications on a regular basis?*
Please describe:
5. Have you had any major injuries, diseases, or ailments in the past five years?*
If yes, please explain:
6. Are you a vegetarian or are you on a restricted diet?*
If yes, please explain:
7. Are you currently under care from a physician?*
If so, please explain:
8. Any additional information (concerning medical conditions or disabilities) that would be helpful for this to be aware of during the Religious Life activity, please provide here:
By providing my name below, I certify that all responses made on this
Health Information Form are true and accurate.*
Date:*
  MM DD YYYY
/ /
Enter the text you see in the security image:


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