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Medical History

Step 1 of 5

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  • Date Format: MM slash DD slash YYYY
  • IDENTIFYING INFORMATION:

  • ALLERGIES/TYPE OF REACTION:

  • IMMUNIZATIONS HISTORY: (PLEASE PROVIDE RECORDS)

    Patients not current with their immunizations cannot be accepted for admission. Please request to speak to the Admission’s Nurse prior to admission date should you have any questions regarding immunizations. Immunizations are not provided at Meridell.
  • MEDICAL / HEALTH, PAST OR CURRENT

  • MEDICAL/PHYSICAL ISSUES CREATING BARRIERS TO LEARNING:

    Describe:
  • CONDITIONS REQUIRING ONGOING MEDICAL OVERSITE:

    Describe:
  • PRE-ADMISSION PROTOCOLS FOR PRE-EXISTING MEDICAL CONDITIONS: