XAVIER UNIVERSITY RISK MANAGEMENT & INSURANCE 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the General Information section. Indicate your gender, last name, first name, middle name, and birth date. Ensure all fields are completed accurately.
3. Provide your Permanent Mailing Address including street, city, state, zip code, and telephone number.
4. In the Health Problems section, list any ongoing health issues you may have. If none apply, simply write 'none'.
5. Detail any drug allergies and reactions in the designated area. Again, if there are none, write 'none'.
6. List any medicines you regularly take in the Medicines section. Include both prescription and over-the-counter medications.
7. Check any relevant medical history items from the provided list and provide explanations where necessary.
8. Indicate your TB skin test results and any TB medicines taken.
9. Complete the Family Medical History section by checking applicable health problems within your family.
10. Use the additional space to inform about anything else that is not covered by this form that we should be aware of.
11. Finally, sign and date the form at the bottom to certify that all information is accurate before submitting it through our platform.

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