Forms

Please Note! To use our forms you will need Adobe Reader or Adobe Acrobat. If you need a copy of the free Adobe Reader click here

For ND Athletes:
The following forms are to be filled out by all Notre Dame Athletes and returned to University Health Services prior to their physical exam.

• Athlete Medical History Questionaire 2011-2012
• Athlete Nutrition Questionaire 2011-12
• Athlete Pre-participation Questionaire 2011-2012
• Participation Physical Evaluation-Returnees only 2011-2012
• Athlete’s Medical Information Release Form
  
  

Note! Female athletes should also complete the following form:

• Female Athlete Screening Form 2011
  
  
  Insurance Forms:
  For the 2010-2011 academic year, all forms will be online with the School Sponsored Insurance Plan Provider
  ON CALL – Worldwide Medical Information and Assistance
  

Others:

• Allergy Service Survey
• Authorization Form for Consent for Treatment of a Minor
• Consent to Acquire Information from Medical Record to release to UHS
• Medical History and Physical report – Online Student Health
  Please Note! Summer or Early students will not be able to access the module til 5/20 and Fall students cannot access it til 6/20. Verification can be mailed to UHS prior to entering the immunization information on line BUT students will be expected to go back to the module after the above dates and enter the information.

Information and forms for students on allergy immunotherapy

• Instructions for using the New Online Student Health
• Medical Information Release Form
• Meningitis Information Signature Form
  (To submit signature acknowledging receipt of Meningitis information)
• Patient Satisfaction Survey
• Post Travel Survey
• Prescribed Stimulant Medication Form
• Refusal of care against medical advice form
• Travel Service Survey