Medical Survey This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.About YouYour Name(Required) First Last Date of Birth MM slash DD slash YYYY Your Email Address(Required) Enter Email Confirm Email Medical QuestionnairePlease select the medical condition/s you may have Epilepsy Diabetes Asthma Heart Condition Blood Disorder Allergies EpilepsyType of seizure/s?How long do your seizures typically last?How often do you typically have seizures?When was your last seizure?What is a typical recovery for you following a seizure?Is an ambulance required if you have a seizure, or only in certain circumstances? Please explain exactly when one is requiredDo you use recovery medication? Yes No Do you want to store some at college? Yes No Would college staff need to be trained to administer the emergency medication? Yes No Do you have any medical evidence of your condition? Yes No E.g. Evidence of appointments, reviews from medical personnel or information on how to manage your condition from epileptic nurses etc.Please upload relevant documentation hereMax. file size: 50 MB.DiabetesWhat type of diabetes do you have? Type 1 Type 2 Do you take medication for your diabetes? Yes No Please list the medication and dosages you takeDo you have any medication, equipment, or glucose that you want to store at college for emergencies? Yes No Do you have any medical evidence of your condition? (Diabetes) Yes No Eg. Evidence of appointments, reviews from medical personnel or information on how to manage your condition from the diabetic nurses etc.Please upload relevant documentation hereMax. file size: 50 MB.AsthmaDo you have inhalers? Yes No When do you need to use your inhalers?Do you carry your inhalers with you? Yes No Do you need to store a spare inhaler at college for emergencies Yes No Do you have any known triggers for your asthma?Do you have any medical evidence of your condition? Yes No Eg. Evidence of appointments, reviews from medical personnel or information on how to manage your condition from the diabetic nurses etc.Please upload relevant documentation hereMax. file size: 50 MB.Heart ConditionWhat Heart Condition do you have?How does this specifically affect you?Is there a specific scenario when college should become concerned? Yes No Please provide details including what college should do? E.g. call an ambulanceDo you take any medication for your Heart condition? Yes No Please provide names and dosage of medication takenDo you need to store any medication at college for emergencies? Yes No Do you have any medical evidence of your condition? Yes No Eg. Evidence of appointments, reviews from medical personnel or information on how to manage your condition from the diabetic nurses etc.Please upload relevant documentation hereMax. file size: 50 MB.Blood ConditionWhat is the blood condition you have?How does your blood condition affect you?Is there a scenario when college should become concerned? Eg. The length of time you might take to stop bleeding if you cut yourselfDo you take any medication for your Blood condition? Yes No Please provide names and dosage of medication takenDo you need to store any medication at college in case of emergencies? Yes No Do you have any medical evidence of your condition? Yes No Eg. Evidence of appointments, reviews from medical personnel or information on how to manage your condition from the diabetic nurses etc.Please upload relevant documentation hereMax. file size: 50 MB.AllergiesWhat are you allergic to?Are these allergies airborne, touch or ingest?(Please be specific about each allergy)Do you have any specific signs and symptoms of an allergic reaction?(Please be specific about each allergy)Do you take any medication for your allergies? Yes No Please name any medication you take and dosage(Please be specific about each allergy)Do you have an epi pen/jext pen? Yes No Do you need to store any medication at college in case of emergencies? Yes No Do you have any medical evidence of your condition? Yes No Eg. Evidence of appointments, reviews from medical personnel or information on how to manage your condition from the diabetic nurses etc.Please upload relevant documentation hereMax. file size: 50 MB.PhoneThis field is for validation purposes and should be left unchanged.