New Life Girls Home Medical Records Form

To be completed and signed by the Students Physician

Name: Doctor: Doctor's Address: Complete Medical: Date of Last Blood Work: Date of Last Internal/Pap Test: Date of Late Period or Pregnancy Test, Specify: The following are required testing for admittance into the program: STD Test: TB Test: Hep C Test: Date of Last Tetanus Shot: *Allergies: Food Allergies: Other Food Restrictions (please explain): Other Allergies: Do you suffer from asthma or require and Epipen: *Current Medications and Details: HIV Test: Hep B Test: Hep B Vaccine: *Follow-Up Required: *Any Concerns: Health Card #: Doctor's Phone:

Medical Alert Information:

*Any other Medical Problems To Be Aware Of:

Doctor's Signature:

Date:

THIS FORM MUST BE COMPLETED AND FORWARDED WITH THE STUDENT APPLICATION IN ORDER TO APPLY TO THE PROGRAM *Please use the back of the sheet if space is required