CURRENT HEALTH Yes No while in nursing school, PROBLEMS: including over-the-counter medications. List below. 56. Are you currently in psychiatric Counseling? __________________________ 57. Do you have a chronic disease? (specify) __________________________ 58. Physical disability (type) 59. Learning disability __________________________ 60. Visual impairment (describe) 61. Hearing loss __________________________ 62. Hearing aid 63. Crutches, brace or prosthesis? __________________________ 64. Loss of a paired organ (e.g., eye, lung, kidney) Which __________________________ organ? Which side? __________________________ 65. Are you currently treatment for any medical __________________________ problem? If so, describe on back. __________________________ Medications you are taking that you expect to continue taking __________________________
CURRENT HEALTH PROBLEMS: Yes No 56. Are you currently in psychiatric Counseling? 57. Do you have a chronic disease? (specify) 58. Physical disability (type) 59. Learning disability 60. Visual impairment (describe) 61. Hearing loss 62. Hearing aid 63. Crutches, brace or prosthesis? 64. Loss of a paired organ (e.g., eye, lung, kidney) Which organ? Which side? 65. Are you currently treatment for any medical problem? If so, describe on back. Medications you are taking that you expect to continue taking while in nursing school, including over-the-counter medications. List below. __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________
TC-Nursing-Graduate-Program-Forms-Appendices-160630-1.docx