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CELCIS Health History |
______ |
In order for us to evaluate your
physical and mental health care needs should you become a CELCIS student, we
ask that you complete the following health history questions and return this
form with your CELCIS application package. You may need help from a health care
professional or translator to complete this form. All information will be kept
confidential. (Please type or print clearly) |
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First
Name:_______________________Last Name:________________________ Sex: ____Male
____Female
Height________ Weight________ Age________ Date of Birth: ________/________/____________ Country of citizenship:_____________________________________________________________________________ U.S. Social Security Number(student number), if any: _________________________________________________________ ____________ ______________________________________________________________________________________ Personal Medical History
__ Others (Please list)___________________________________________________________ ____________________________________________________________________________ Previous surgeries_____ __None __Yes (if yes, explain below) type___________________________________________________ Date__________ type___________________________________________________ Date__________ Previous hospitalizations_____ __None __Yes (if yes, explain below) reason___________________________________________________ Date__________ reason___________________________________________________ Date__________ Medical treatment authorization For patients under the age of eighteen (18) to be seen at WMU's Sindecuse Health Center, a parent or guardian must complete and sign the statement below. Completion of this part of the form is extremely important in order to obtain medical care in the United States. I hereby authorize WMU's Sindecuse Health Center to administer medical treatment to my son/daughter. This authorization is effective from the date of signature until the patient is of legal age or ineligible to use the facility's services. Minor's name (printed) ________________________________________________ Student Number _______________________ Parent or guardian's signature ________________________________________ Date __________________________________ Parent or guardian's name printed) ___________________________________________________________________________ Health Insurance Western Michigan University and CELCIS require students to carry insurance to cover medical expenses while in the United States. Please let us know which of the following statements applies to you: __ I do not need insurance because my medical expenses are fully covered by a spnsor. Sponsor's name ____________________________________________________________ __ I will be bringing health insurance with me. Note: Minimum insurance coverage must be $50,000, translated in English, and cover you through the entire semester/session. Bring your insurance information to the CELCIS office for approval upon registration. __ I will need the insurance offered through CELCIS. I certify that all information on the CELCIS Health History form is complete and accurate to the best of my knowledge. Failure to report or to provide complete medical information will invalidate my application and may result in dismissal if I am admitted to CELCIS. Signature of applicant___________________________________________________ Date__________ Printed Name of applicant___________________________________________________ |
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