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Student status:
You must be a: Freshman, Sophomore , Junior, Senior,
Graduate, Post Graduate Student
enrolled in a state accredited college or university taking 9 or more credit
hours
You must be able to
answer no to the following questions:
1. In the past 15 days, have you taken
prescription medication for any medical condition
(this does not include birth control medication taken for the
prevention of pregnancy),
or been seen by a member of the medical profession for a medical
condition, or
been hospital confined? Yes_____ No
_____
2. In the past 12 months, have you either been recommended to have or been
scheduled for
diagnostic testing, treatment, or surgery that has not been
completed? Yes____ No_____
3. Within the last 5 years, have you received any tests or medical
treatment, or surgical treatment, or
consulted a physician , or taken medication for:
Yes ______ No _____
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heart disorder including heart attack or
chest pain,
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stroke,
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diabetes
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stomach or duodenal ulcer or ulcer
symptoms or colitis or Crohns disease
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uncorrected gall bladder disease or
gallstones
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kidney disease
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cancer, tumor or internal cyst
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immune system disorder including
acquired immune deficiency syndrome
(AIDS) or tested positive for HIV
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alcoholism or alcohol abuse
chemical dependency or drug abuse
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