School of Nursing
Change in Health Status Form
Questions 1and 2 of this form must be completed at the beginning of each semester (1/15 and 8/15) AND
within 48 hours of a change in medical history or health status.
Question 1A: List ALL current medical diagnosis or write N/A.
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Question 1B: Changes in medical history over the past 4 months. Please provide a yes/no answer for all 5 questions.
1. Have you received a new medical diagnosis? YES NO
2. Have you been hospitalized? YES NO
3. Have you had any surgeries? YES NO
4. Have you experienced any physical injuries (neck, back, arms, legs, etc)? YES NO
5. Do you have any lifting limitations? YES NO
If you answered yes to question 1B, please explain and attach a full medical release.
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Question 1C: Are you currently pregnant? (Females only) YES NO
If you answered yes to question 1C, please attach a full medical release with no restrictions, and your expected date of
delivery.
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Question 2A: Prescription Medications. List all current prescription medications or write NA. Do not leave blank.
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Signature SU Banner Student Number
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Printed Name Date
Revised 12/21
