Delaware State University
Office of International Affairs
1200 N. Dupont Highway
Dover, DE 19901
Medical Form
Please complete the information requested and submit the form to Mrs. Candace Alphonso-Moore, Grossley Hall, 115,
NO PHOTOCOPIES OR FAXES WILL BE ACCEPTED!!!
Name__________________________________________
D#
Email:
Program Location (Country):_
____________________________________________
When did you last consult a physician and why?___________________________________________________________
Have you had any diseases, ailments, or injuries in the past 5 years? [ ] Yes
[ ] No
If yes, please explain_________________________________________________________________________________
Do you have asthma? [ ] Yes
[ ]No
If yes, do you [ ]take medication [ ]have an inhaler?
[ ]Other__________________________________________________________________________________
If the past 5 years, have you been treated by a mental health practitioner (psychologist, social worker, or psychiatrist) for
any of the following (please provide additional information if necessary):
[ ] Depression
[ ] Family Concerns
[ ] Anxiety
[ ] Bulimia
[ ] Drug addition or abuse
[ ] Alcohol addition or abuse [ ] Anorexia
[ ] Panic Disorder
[ ] Other (please explain)_____________________________________________________________________________
Blood Type ______________________
Please list any allergies including those to medication:______________________________________________________
__________________________________________________________________________________________________
If you are on a restricted diet, please provide specific details:_________________________________________________
__________________________________________________________________________________________________
Have you received the recommended immunizations?
[ ] Yes If yes, where did you receive your immunizations? (name of medical facility)
______________________________________________ on ____________________________ (Date).
[ ] No If no, by signing below “I am aware of the recommended immunizations and I made a conscious decision not to
get them; furthermore, I do not hold Delaware State University responsible for any illnesses I may contact due to my
conscious decision NOT to receive the recommended immunizations.”
I have answered the above questions correctly to the best of my knowledge.
__________________________________________
Signature of student
____________________________
Date