We are asking you to fill out this medical information sheet for precautionary measures only. In the event of a medical emergency, this form will be a source of reliable information. A copy will be sent to our office manager in Budapest.

1. Name:
   

2. Semester(s) Participating

   Fall Spring Both in the academic year

3. Permanent home address:
   

   Home Phone:
   

4. Name and address of next of kin or person to be notified in case of emergency:
   
   Phone if different from above:
   

5. Birth date
   

6. Social security number
   

7. Permanent insurance carrier and your code number
   

8. Height (centimeters)
   

9. Weight ( kilos )
   

10. Do you wear glasses? Yes No

11. Do you wear contacts? Yes No

12. Prescription information (if available)
    

13. Allergies to:
    foods
    animals
    insects
    dust
    smoke
    pollen
    other
    

    If you answered "yes" to any of the above allergy questions, please be more specific if you think it is necessary.

14. Allergies to drugs?
    Yes No

    If yes, please list
    

15. Blood type and RH factor
    Blood Type ABABO RH Factor RH+RH-
    

16. Preconditions: Do you have
    asthma
    depression
    diabetes
    hay fever
    heart condition
    high blood pressure
    seizures (fainting)
    other
    

17. If you answered "yes" to any of the above medical preconditions, please provide specific details.

18. Are you on any medication? Yes No

19. If yes, please list all medications and dosages
    

20. Comments (anything which you think might be useful medical information)
    

21. Please include a complete copy of your current immunization record.