The following health history is confidential, does not affect your admission status and, except in an emergency situation or by court order, will not be released without your written permission. Please attach additional sheets for any items that require further explanation.
Have YOU ever had or have YOU now: (please check all that apply)
Check each item YES or NO. Every item checked YES must be fully explained in the space on the right.
Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash, hives, etc.) to any of the following? If yes please explain fully the type of reaction, your age when the reaction occurred, and if the experience has occurred more than once.
Check all the required vaccinations that you have completed (this should be what is represented on the form you upload):