STUDENT HEALTH FORM

Please note that you do not have to fill in the parts of the form that do are not appended with (required), but please be aware that I cannot offer modifications or alternatives for physical conditions that have not been declared.

Personal Details

Name

First Name

Last Name

Address

Phone

Country

(###)

###

####

Emergency Contact

Health

Relevant Health Problems

Have you had any major health problems in the past or are you currently dealing with the medical profession? Such problems might include high or low blood pressure, recent surgery, epilepsy, diabetes, serious injury or accident, asthma, ulcers, hernias, arthritis, problems with the back, the heart, knees, eyes, ears, or mental health.

If you are pregnant, how many weeks?

Is there anything else you would like to tell me?

Please tick this box if you DO NOT wish to declare physical and/or mental health information

It is your right to withhold information but we must inform you that if you do not disclose your health status, I cannot give modifications or alternatives for physical conditions that have not been declared, and will be unaware of anything that might casue emotional distress or otherwise exacerbate any mental health issues.

I DO NOT wish to disclose physical or mental health information

Please tick this box to confirm you have read the Student Health Terms & Conditions located HERE

I have read the Student Health Terms & Conditions