SAT Sabbatical
 School of Applied Theology • GRADUATE THEOLOGICAL UNION, Berkeley
5890 Birch Court, Oakland, CA 94618-1626 • Tel. (510) 652-1651
U.S. & Canada: 1-800-831-0555 • FAX: (510) 420-0542 •  E-Mail: satgtu@aol.com

HEALTH ASSESSMENT FORM
To be completed by Applicant

Name: _________________________________________________________

(last)

(first)

(middle)

Address ________________________________________________________

_______________________________________________________________

_______________________________________________________________

Date of Birth: ____________		 Height: _______

Weight:______

Occupation: _____________________________________________________

 

MEDICAL HISTORY
Have you ever had or have you now any of the following conditions?
Please check if applicable.

___ Frequent or severe headaches ___ Sugar or albumin in urine
___ Dizziness or fainting spells ___ Epilepsy or fits
___ Unconscious for any reason ___ Nervous/ emotional trouble
___ Eye trouble ___ Motion sickness requiring drugs
___ Hay fever ___ Military medical discharge
___ Asthma ___ Heart trouble
___ Kidney stones or blood in urine ___ Admission to hospital
___ Treatment for addiction ___ Treatment for addiction
___ Allergic reactions to any drugs? ___ Depression or other psychological illness

___ Other illnesses? Specify:

____________________________________________________________________________________________

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