Health Form

Name of Applicant*

Age*

Email Address

Address*

HISTORY

Are you subject to the following:

Do you get tired easily?*

Do you wear glasses?*

Give the date of your last eye examination:*

Do you require a special diet?*

If Yes, please explain more.*

Have you ever had the following:

Other Illness

Has there been any recurrence of or complications resulting from above illness?*

If Yes, please explain more.*

Have you had any surgeries?*

Are you on any medication?*

Do you need to keep taking any kind of medicine?*

While ZMI will try to help protect the safety and health of each student, I understand that ZMI is not responsible to ensure or to guarantee the safety and health of any student. I will be responsible to pay any medical bills that I may incur while a student at ZMI, and I release ZMI from any such claims.*

Agree

Not Agree

Signature*

Submission Date*