GARDNER COLLEGE
– A Centre for Christian Studies –
Camrose, Alberta
CONFIDENTIAL HEALTH QUESTIONNAIRE
FORM C

NAME ________________________________________________________
HEALTH CARE NUMBER________________________________________

Do you wear a medical alert bracelet? [ ] Yes [ ] No
If so, state reason _______________________________________

Do you have any known allergies? [ ] Yes [ ] No

What medications do you take regularly?_______________________________________________________
What medications do you take occasionally?___________________________________

Have you ever suffered from or, received treatment for Tuberculosis? [ ] Yes [ ] No
*Date of last TB test ______________________
*Date of last Tetanus injection _____________________

Do you have a speech problem? [ ] Yes [ ] No

Do you have a hearing problem? [ ] Yes [ ] No

Do you have a vision problem? [ ] Yes [ ] No

Date of last eye exam. __________________________
(The applicant is urged to have an eye examination before entering college.)

Date of last physical exam. ________________________
(The applicant is urged to have a physical examination before entering college.)

Do you have any physical limitations? [ ] Yes [ ] No

Are you subject to any of the following?

Asthma [ ] Yes [ ] No

Diabetes [ ] Yes [ ] No

Epilepsy [ ] Yes [ ] No

Fainting spells/Dizziness [ ] Yes [ ] No

Hayfever [ ] Yes [ ] No

Heart Problems [ ] Yes [ ] No

Tonsilitis [ ] Yes [ ] No

Ulcer [ ] Yes [ ] No

Do you consider yourself capable of participating in a physical education program and a normal school life? [ ] Yes [ ] No

If no, please submit a letter from your physician to verify this.

Are there any other health conditions that you believe the college should be aware of? (Use additional paper if necessary.)

* Immunizations: ALL students are encouraged to have their immunizations updated. ALL ECD STUDENTS are REQUIRED to have current immunizations.

I affirm that the above information is true and complete to the best of my knowledge.








_____________________________________________________________________
Student’s SignatureDate

Please return this CONFIDENTIAL form to:


Attention: Registrar
Gardner College
4704 – 55 Street
Camrose, Alberta T4V 2B6