{ "document_id": 12840, "page": 1, "width_pt": 612, "height_pt": 792, "rotation": 0, "pipeline_version": "paddleocr-vl-1.6+paul-48", "engine": "paddleocr_vl", "source_run_id": 12951, "item_count": 29, "counts_by_type": { "figure": 1, "form_field": 9, "heading": 2, "list": 2, "list_item": 12, "text": 2, "title": 1 }, "build_ms": 2, "items": [ { "id": "p1.1", "order": 1, "type": "figure", "bbox": { "l": 72.72, "t": 719.52, "r": 156.48, "b": 635.28 }, "text": "", "attrs": { "role": "page_header", "block_label": "header_image" } }, { "id": "p1.2", "order": 2, "type": "title", "bbox": { "l": 215.04, "t": 655.2, "r": 484.32, "b": 628.08 }, "text": "Medical History Form", "attrs": { "block_label": "doc_title" }, "level": 2 }, { "id": "p1.3", "order": 3, "type": "heading", "bbox": { "l": 69.84, "t": 608.4, "r": 207.84, "b": 597.36 }, "text": "Instructions and information:", "attrs": { "block_label": "paragraph_title" }, "level": 3 }, { "id": "p1.4", "order": 4, "type": "list", "bbox": { "l": 87.36, "t": 582, "r": 537.12, "b": 489.84 }, "text": "", "attrs": { "item_count": 3 }, "children": [ { "id": "p1.4.1", "order": 5, "type": "list_item", "bbox": { "l": 87.84, "t": 582, "r": 533.52, "b": 556.8 }, "text": "We require this form be returned to the address below within 30 days or no later than 14 prior to enrollment. All pages must be completed.", "marker": "1." }, { "id": "p1.4.2", "order": 6, "type": "list_item", "bbox": { "l": 87.36, "t": 554.88, "r": 535.68, "b": 516.96 }, "text": "We recommend this form be completed by all new students and students who have been away from the University for more than 10 months. We also recommend students entering graduate school complete this form.", "marker": "2." }, { "id": "p1.4.3", "order": 7, "type": "list_item", "bbox": { "l": 87.36, "t": 514.8, "r": 537.12, "b": 489.84 }, "text": "Information on this form is CONFIDENTIAL. It is for Kentucky State University Student Health Services, will not be released without the student's consent and will not affect admission status.", "marker": "3." } ] }, { "id": "p1.5", "order": 8, "type": "text", "bbox": { "l": 85.2, "t": 487.68, "r": 393.6, "b": 410.16 }, "text": "4. Send completed forms to: Student Health Services\nKentucky State University\n400 East Main Street\nFrankfort, KY 40601\nFax: (502) 597-6565 or\nScan to: Samantha.Todd@kysu" }, { "id": "p1.6", "order": 9, "type": "heading", "bbox": { "l": 70.08, "t": 394.32, "r": 148.32, "b": 382.32 }, "text": "IDENTIFICATION", "attrs": { "block_label": "paragraph_title" }, "level": 3 }, { "id": "p1.7", "order": 10, "type": "list", "bbox": { "l": 68.4, "t": 367.92, "r": 540.72, "b": 126 }, "text": "", "attrs": { "item_count": 9 }, "children": [ { "id": "p1.7.1", "order": 11, "type": "list_item", "bbox": { "l": 69.84, "t": 367.92, "r": 540.72, "b": 354.48 }, "text": "CWID # (see acceptance letter): ___ SSN: ___", "children": [ { "id": "p1.7.1.1", "order": 12, "type": "form_field", "bbox": { "l": 72.025, "t": 366.13, "r": 539.4285, "b": 355.13 }, "text": "", "attrs": { "field_kind": "text", "label": "CWID # (see acceptance letter): ___ SSN: ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p1.7.1" } } ] }, { "id": "p1.7.2", "order": 13, "type": "list_item", "bbox": { "l": 69.6, "t": 340.8, "r": 537.84, "b": 326.88 }, "text": "Name (Last, First, Middle): ___", "children": [ { "id": "p1.7.2.1", "order": 14, "type": "form_field", "bbox": { "l": 72.025, "t": 339.35, "r": 535.1785, "b": 328.35 }, "text": "", "attrs": { "field_kind": "text", "label": "Name (Last, First, Middle): ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p1.7.2" } } ] }, { "id": "p1.7.3", "order": 15, "type": "list_item", "bbox": { "l": 68.4, "t": 314.64, "r": 538.32, "b": 274.08 }, "text": "Home Address (Number and Street): ___", "children": [ { "id": "p1.7.3.1", "order": 16, "type": "form_field", "bbox": { "l": 72.025, "t": 312.35, "r": 536.4285, "b": 301.35 }, "text": "", "attrs": { "field_kind": "text", "label": "Home Address (Number and Street): ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p1.7.3" } }, { "id": "p1.7.3.2", "order": 17, "type": "form_field", "bbox": { "l": 72.025, "t": 285.6, "r": 538.0986, "b": 274.6 }, "text": "", "attrs": { "field_kind": "text", "source": "blank_line", "label": "Home Address (Number and Street): ___", "label_source": "parent_text", "label_ref": "p1.7.3" } } ] }, { "id": "p1.7.4", "order": 18, "type": "list_item", "bbox": { "l": 70.08, "t": 273.12, "r": 470.64, "b": 260.16 }, "text": "City State Zip Code Country" }, { "id": "p1.7.5", "order": 19, "type": "list_item", "bbox": { "l": 69.6, "t": 246.96, "r": 538.32, "b": 233.04 }, "text": "Home Telephone: ( ) ___", "children": [ { "id": "p1.7.5.1", "order": 20, "type": "form_field", "bbox": { "l": 72.025, "t": 245.33, "r": 536.8486, "b": 234.33 }, "text": "", "attrs": { "field_kind": "text", "label": "Home Telephone: ( ) ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p1.7.5" } } ] }, { "id": "p1.7.6", "order": 21, "type": "list_item", "bbox": { "l": 70.32, "t": 220.56, "r": 539.28, "b": 206.16 }, "text": "Cell Phone: (___)", "children": [ { "id": "p1.7.6.1", "order": 22, "type": "form_field", "bbox": { "l": 72.025, "t": 218.33, "r": 537.9285, "b": 207.33 }, "text": "", "attrs": { "field_kind": "text", "label": "Cell Phone: (___)", "source": "blank_line", "label_source": "parent_text", "label_ref": "p1.7.6" } } ] }, { "id": "p1.7.7", "order": 23, "type": "list_item", "bbox": { "l": 70.08, "t": 193.2, "r": 537.84, "b": 179.52 }, "text": "Email: ___", "children": [ { "id": "p1.7.7.1", "order": 24, "type": "form_field", "bbox": { "l": 72.025, "t": 191.55, "r": 535.1785, "b": 180.55 }, "text": "", "attrs": { "field_kind": "text", "label": "Email: ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p1.7.7" } } ] }, { "id": "p1.7.8", "order": 25, "type": "list_item", "bbox": { "l": 70.32, "t": 166.56, "r": 539.76, "b": 152.88 }, "text": "Date of Birth (Month-Day-Year): ___", "children": [ { "id": "p1.7.8.1", "order": 26, "type": "form_field", "bbox": { "l": 72.025, "t": 164.55, "r": 538.6785, "b": 153.55 }, "text": "", "attrs": { "field_kind": "text", "label": "Date of Birth (Month-Day-Year): ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p1.7.8" } } ] }, { "id": "p1.7.9", "order": 27, "type": "list_item", "bbox": { "l": 70.08, "t": 139.2, "r": 224.88, "b": 126 }, "text": "Sex: ___Male ___Female" } ] }, { "id": "p1.8", "order": 28, "type": "text", "bbox": { "l": 69.6, "t": 112.56, "r": 537.36, "b": 71.76 }, "text": "Emergency Contact Information (Name and Telephone Number – PLEASE PRINT):", "children": [ { "id": "p1.8.1", "order": 29, "type": "form_field", "bbox": { "l": 72.025, "t": 84.025, "r": 537.9855, "b": 73.025 }, "text": "", "attrs": { "field_kind": "text", "source": "blank_line", "label": "Emergency Contact Information (Name and Telephone Number – PLEASE PRINT):", "label_source": "parent_text", "label_ref": "p1.8" } } ] } ], "excluded_furniture": { "first": [], "last": [] } }