• Seminarian Application – Step 3: Health Packet

    Complete your health, dental, emergency, and insurance details (about 15–20 minutes); you can save and return later.
  • This step takes about 20–30 minutes. You can save and come back anytime. Your physician and eye doctor complete their own forms separately — we email them for you.

  • About You

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Medical History

  • Please check any symptom or condition that applies to you
  • Do you have any drug allergies?*
  • Are you currently on any form of medication?*
  • Do you smoke?*
  • History of alcohol abuse?*
  • History of drug abuse?*
  • Has your physical activity been restricted in the past five years?*
  • Have you received treatment or counseling for any nervous condition, personality or character disorder, or emotional problems?*
  • Have you been hospitalized for any illness or injury not already mentioned?*
  • Have you been under a physician's care for an extended period?*
  • Have you been rejected for or discharged from military service for physical, emotional or other reasons?*
  • Do you have health or family-history questions you would like to discuss?*
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • Physician & Emergency

  • Do you have a regular physician?*
  • Format: (000) 000-0000.
  • Do you wear any of the following?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Dental History

  • How often do you receive dental care?*
  • Approximate date your teeth were last cleaned
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you ever been treated for a painful mouth infection?
  • Have you ever had trench mouth?
  • Are any of your teeth loose?
  • Have you ever been treated for periodontal disease?
  • Have you ever had your teeth straightened?
  • Do your jaws ever feel tired?
  • Do you have pain in or near your ear?
  • Do you grind your teeth during the day or at night?
  • Does food catch between your teeth?
  • Do heat, cold, or sweets cause pain?
  • When do you brush your teeth?
  • Do you use anything other than a toothbrush?
  • Do your gums bleed when brushing?
  • Do you have a bad taste in your mouth?
  • Have you ever had a gum abscess (gum boil)?

  • Medical Insurance

  • All diocesan seminarians MUST have medical insurance. If you don't have it, the Diocese will provide it; the Diocese pays 75% and you pay 25% through your student loan. If you are covered through your own or your family's insurance, the Diocese pays only up to the 75% it pays for diocesan insurance. Once ordained a deacon, the Diocese pays 100%.
  • Do you have medical insurance?*
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • Certification & Signature

  • Certification Statement
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: