Get Confidential Medical Record Form - Naropa University - Naropa

Filling out the Confidential Medical Record Form is an essential step for prospective and current students participating in the Wilderness Therapy program at Naropa University. This guide will walk you through each section of the form, ensuring you provide the necessary information accurately and completely for your safety and well-being.

Follow the steps to accurately complete the Confidential Medical Record Form.

1. Press the ‘Get Form’ button to access the Confidential Medical Record Form and open it for editing.
2. In Part I: General Information, provide your full name, birth date, address, city/state/ZIP code, phone numbers, email address, emergency contact name and phone number, age, height, weight, family physician's name and contact details, and your insurance information including policy number.
3. In Part II: Medical Information, indicate if you have any medical conditions by checking 'None' or listing them. Detail any medications you are currently taking, including dosages and any side effects. It is also important to list any allergies you have.
4. In Part III: Health Profile, answer the questions regarding your health history including smoking status, any pregnancies, seizure history, family heart attack history, hospitalizations in the last two years, emergency department visits in the past year, and any other medical requirements. Provide details for any issues that apply.
5. In Part IV: Do I Need A Physical Examination?, indicate yes or no for the listed health problems and add any additional comments. This includes conditions like high resting pulse or blood pressure readings, chest pain, heart disease, and more.
6. Finally, in Part V: Signature Required, read the statement carefully. After ensuring all provided information is accurate, sign and date the form to confirm your understanding and agreement regarding the wilderness therapy program.
7. Once you have completed the form, you can save your changes, download the document, print it for your records, or share it with your admissions counselor.

Complete your Confidential Medical Record Form online today to ensure a smooth admission process.