Phlebotomy Health History Form

Short-Term Training

Phlebotomy Health History
Name*

First NameMiddle NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*
Are you interested in learning more about accommodations for your training?*

YesNo
It is the trainee's responsibility to self-identify as needing accommodations in a timely manner and seek information, guidance, and assistance from the appropriate College resources, preferably six weeks before the start of training. Learn more about Mid's Accommodation Services or request more information.
Can we share your information with Mid's Accommodation Services team?*

YesNo
Have you been under the care of a physician within the last year?*

YesNo
Physician Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone

Area CodePhone Number
Have you been taking any medication regularly in the last year?*

YesNo
For trainings that require a drug screen, it is recommended that you inform the screening facility about any prescribed medications you are taking.
Check all of the following you have experienced in the past three weeks:*

FeverChillsNight SweatsLoss of AppetiteCoughing Up BloodWeight LossFatigueI have not experienced any of these symptoms
Please tell us when you experienced these symptoms and provide any circumstances that help contextualize your experience. (ie flu, cold, etc.)
Can you lift a minimum of 50 pounds?*

YesNo
If not, please explain.
Students must have a TB test and bring proof of such on the first day of class. TB testing is available from the Health Department or from your doctor.

Students will also need to provide up-to-date immunization records for the Hepatitis B, MMR (Measles, Mumps & Rubella), Varicella, Tdap (Tetanus, Diphtheria & Pertussis), and a seasonal flu vaccine.
Signature*

Clear
Today's Date*

MonthDayYear
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Short-Term Training