COLUMBIA COLLEGE HEALTH SERVICES
HEALTH SCREENING FORM FOR FIRE ACADEMY STUDENTS
FIRST & LAST NAME:
*
GENDER AT BIRTH:
FEMALE
MALE
BIRTHDATE:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
AGE
*
Primary Care Office:
Current Medications (Prescription, over the counter medicines, or supplements):
Allergies (Medications or other):
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COLUMBIA COLLEGE HEALTH SERVICES HEALTH SCREENING FORM FOR FIRE ACADEMY STUDENTS
MEDICAL SCREENING (ONLY MARK YES OR NO COLUMNS)
MEDICAL SCREENING
Rows
YES
NO
Asthma
Surgery
Organs Removed
Heat Exhaustion/Heat Stroke
Seizures
Concussion/Dates
Hearing
Liver/Kidney/Spleen
Hernia
Skin Disorders
Bone/Joints
Diabetes
Heart Condition
Other
Academy Student Signature:
*
DATE:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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