APPLICANT MEDICAL REPORT

Applicant Medical Report
Instructions
A physican's medical exam is not required for completion of this form. However, a sports physical provided by a medical physician will be required to play intercollegiate sports. Evaluation for acceptance will not occur until ABC receives the completed medical form.
Applicant's Name
Age
Gender
E-mail Address
Immunization Dates
The West Virginia Higher Education Policy Commission requires the MMR (Measles, Mumps, and Rubella) immunization(s). You may need to contact your current or childhood physician for help. A date must be entered on each of the following blanks.
Measles
Measles

MonthDayYear
Date
Mumps
Mumps

MonthDayYear
Date
Rubella
Rubella

MonthDayYear
Date
Polio
Polio

MonthDayYear
Date
Tetanus
Tetanus

MonthDayYear
Date
TB (Tine) Test
TB (Tine) Test

MonthDayYear
Date
Other (Please Specify)
Tuberculosis Screening
A tuberculosis screening is required for all individuals applying to Appalachian Bible College. Applicants will be notified if they need to have tuberculosis testing prior to arrival.
Were you born in the U.S.?

YesNo
If no, where were you born?
Have you ever traveled outside the U.S.?

YesNo
If yes, when and where:
Have you ever tested positive for TB disease?

YesNo
Have you ever been employed at a location of high-risk for TB disease (e.g., correctional facilities, homeless shelter, hospitals, nursing homes, or other health facilities)?

YesNo
Have you ever had close contact with a person known or suspected to have TB disease?

YesNo
Have you ever had close contact with high-risk local populations known to have an increased prevalence of TB disease?

YesNo
Have you ever had contact with persons who inject illicit drugs or other groups of high-risk substance abuse users (e.g. crack cocaine)?

YesNo
To the best of your knowledge, are you free from any communicable disease?

YesNo
If no, state the condition:
Is there any reason why you should not participate in physical education classes?

YesNo
If yes, please explain:
Do you have physical conditions, limitations, or handicaps that might prevent your participation in a full-time college study situation?

YesNo
If yes, please explain:
Have you ever discontinued school for health reasons?

YesNo
If yes, please explain:
Have you ever been advised to change your residence, school, or occupation because of your health?

YesNo
If yes, please explain:
Have you ever been under psychiatric care/treatment?

YesNo
If yes, please explain and state the time frame of your treatment:
If you are currently using prescribed anti-psychotic, anti-depressant, or anti-anxiety medication(s), please list:
Please Rate Your General Health Condition

PoorFairGoodExcellent
Certification of Health Report
I certify that the information contained on this form, to the best of my knowledge, is both accurate and complete.
Applicant Name
Applicant Date of Birth

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Parent/Guardian Name
Parent Date of Birth

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Medical Emergency Authorization
In the event of emergency:

I give my permissionI do not give my permission
for the College Nurse, or other responsible officials of Appalachian Bible College, to act, or give authorization in my behalf, to a physician or licensed paramedic, to take whatever emergency measures necessary for the well-being of the applicant stated during his/her enrollment at ABC.
Applicant Name
Applicant Date of Birth

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Parent/Guardian Name
Parent Date of Birth

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Should be Empty:

Applicant Medical Report

Instructions

Immunization Dates

Tuberculosis Screening

Certification of Health Report

Medical Emergency Authorization