CHAMBERLAIN COLLEGE NURSING National Management …

1 C H AMB ER LAIN C OLLEGE of N U RS I N G. National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | | Please visit for location specific information. CLINICAL PROFILE. TO BE COMPLETED BY STUDENT. Date: Student ID (D#): Program: Campus: Name: Last First Maiden/Other Permanent address: Street City State Zip / / c Male c Female SSN# Date of Birth Phone: Home Cell Work Email: In case of emergency, contact: Name: Last First Relationship Address: Street City State Zip Phone: Home Cell Primary care physician: Name: Phone: Address: Street City State Zip Are you currently seeing a physician, psychiatrist or other healthcare provider? c Yes c No If yes, explain: Please list all current medications you are taking: Please list any allergies: Are you now or have you been treated for (Please check appropriate boxes): c Seizures c High Blood Pressure c Heart Problems c Diabetes c Hepatitis (A/B/C) c Sickle Cell Anemia c Asthma c Depression Other medical problems: Have you ever been hospitalized?

2 C Yes c No Date(s) of hospitalization: If yes, please explain: Submit completed forms to: National Clinical Compliance Office | 3005 Highland Parkway | Downers Grove, IL 60515-5799. Scan and upload your compliance documents to your CHAMBERLAIN /Complio account Comprehensive consumer information is available at 2016 CHAMBERLAIN COLLEGE of NURSING LLC. All rights reserved. 0816ccnlc