Student Health Record

Student Health Record

The information on this form will be used as an aid in providing care, should you need it, while you are a student. It is confidential and will be released only to health care professionals and only when deemed necessary for your health.

YOU WILL NOT RECEIVE A HOUSING ASSIGNMENT UNTIL THIS FORM IS COMPLETED.

Student Information

Name*

First Name

Middle Name

Last Name

What are your preferred pronouns?*

Date of Birth*

What sex were you assigned at birth?*

Male Female Prefer not to say

Permanent Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Emergency Contact Information

Name*

First Name

Last Name

Relationship*

Phone Number*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Health Insurance

If you have health insurance, please fill out the information below. If not, leave all fields below blank.

Current Physician

Insurance Carrier

Address of Insurance Carrier

Address Line 1

Address Line 2

City

State

ZIP Code

Name of Policy Holder

Employer

Policy or Certificate Number

Group Number

Is this an HPO, PPO, or Managed Care?

Yes No

Report of Medical History

The following health history is confidential and does not affect your admission status. Except in an emergency situation by court order, this information will not be released without your written permission. Please attach additional sheets for any items which require further explanation.

About Your Family

Has any person, related to you by blood, had any of the following:*

Has any person, related to you by blood, had any of the following:
	Yes	No
High Blood Pressure?	Has any person, related to you by blood, had any of the following:: High Blood Pressure? (Yes)	High Blood Pressure? (No)
Stroke?	Stroke? (Yes)	Stroke? (No)
Heart Attack Before Age 55?	Heart Attack Before Age 55? (Yes)	Heart Attack Before Age 55? (No)
Blood or Clotting Disorder?	Blood or Clotting Disorder? (Yes)	Blood or Clotting Disorder? (No)
Cholesterol/blood fat disorder?	Cholesterol/blood fat disorder? (Yes)	Cholesterol/blood fat disorder? (No)
Diabetes?	Diabetes? (Yes)	Diabetes? (No)
Glaucoma?	Glaucoma? (Yes)	Glaucoma? (No)
Overweight/Obesity?	Overweight/Obesity? (Yes)	Overweight/Obesity? (No)
Cancer/Type?	Cancer/Type? (Yes)	Cancer/Type? (No)
Alcohol/Drug Problems?	Alcohol/Drug Problems? (Yes)	Alcohol/Drug Problems? (No)
Psychiatric Stress?	Psychiatric Stress? (Yes)	Psychiatric Stress? (No)
Suicide?	Suicide? (Yes)	Suicide? (No)

If you answered "yes" to any of the questions above, please specify here: (include relationship to family member)*

About You

Do you now have or have you ever had any of the following:*

Do you now have or have you ever had any of the following:
	Yes	No
High Blood Pressure?	Do you now have or have you ever had any of the following:: High Blood Pressure? (Yes)	High Blood Pressure? (No)
Rheumatic Fever?	Rheumatic Fever? (Yes)	Rheumatic Fever? (No)
Heart Trouble?	Heart Trouble? (Yes)	Heart Trouble? (No)
Chest Pain/Pressure?	Chest Pain/Pressure? (Yes)	Chest Pain/Pressure? (No)
Shortness of Breath?	Shortness of Breath? (Yes)	Shortness of Breath? (No)
Asthma?	Asthma? (Yes)	Asthma? (No)
Pneumonia?	Pneumonia? (Yes)	Pneumonia? (No)
Tuberculosis?	Tuberculosis? (Yes)	Tuberculosis? (No)
Head/Neck Radiation Treatments?	Head/Neck Radiation Treatments? (Yes)	Head/Neck Radiation Treatments? (No)
Tumor/Cancer? (Please Specify Below)	Tumor/Cancer? (Please Specify Below) (Yes)	Tumor/Cancer? (Please Specify Below) (No)
Maliase?	Maliase? (Yes)	Maliase? (No)
Diabetes?	Diabetes? (Yes)	Diabetes? (No)
Serious Skin Disease?	Serious Skin Disease? (Yes)	Serious Skin Disease? (No)
Mononucleosis?	Mononucleosis? (Yes)	Mononucleosis? (No)
Hay Fever?	Hay Fever? (Yes)	Hay Fever? (No)


	Yes	No
Allergy Shots?	: Allergy Shots? (Yes)	Allergy Shots? (No)
Concussion?	Concussion? (Yes)	Concussion? (No)
Dizziness or Fainting Spells?	Dizziness or Fainting Spells? (Yes)	Dizziness or Fainting Spells? (No)
Paralysis?	Paralysis? (Yes)	Paralysis? (No)
Epileptic Seizures?	Epileptic Seizures? (Yes)	Epileptic Seizures? (No)
Ulcer (Duodenal or Stomach)	Ulcer (Duodenal or Stomach) (Yes)	Ulcer (Duodenal or Stomach) (No)
Pilonidal Cyst?	Pilonidal Cyst? (Yes)	Pilonidal Cyst? (No)
Gall Bladder Trouble?	Gall Bladder Trouble? (Yes)	Gall Bladder Trouble? (No)
Gallstones?	Gallstones? (Yes)	Gallstones? (No)
Jaundice or Hepatitis?	Jaundice or Hepatitis? (Yes)	Jaundice or Hepatitis? (No)
Rectal Disease?	Rectal Disease? (Yes)	Rectal Disease? (No)
Severe/Recurrent Abdominal Pain?	Severe/Recurrent Abdominal Pain? (Yes)	Severe/Recurrent Abdominal Pain? (No)
Hernia?	Hernia? (Yes)	Hernia? (No)
Anemia/Sickle Cell Anemia?	Anemia/Sickle Cell Anemia? (Yes)	Anemia/Sickle Cell Anemia? (No)
Eye Trouble (NOT glasses)?	Eye Trouble (NOT glasses)? (Yes)	Eye Trouble (NOT glasses)? (No)


	Yes	No
Shoulder Dislocation?	: Shoulder Dislocation? (Yes)	Shoulder Dislocation? (No)
Knee Problems?	Knee Problems? (Yes)	Knee Problems? (No)
Recurrent Back Pain?	Recurrent Back Pain? (Yes)	Recurrent Back Pain? (No)
Neck/Back Injury?	Neck/Back Injury? (Yes)	Neck/Back Injury? (No)
Epileptic Seizures?	Epileptic Seizures? (Yes)	Epileptic Seizures? (No)
Broken Bone?	Broken Bone? (Yes)	Broken Bone? (No)
Kidney Infection?	Kidney Infection? (Yes)	Kidney Infection? (No)
Kidney Stones?	Kidney Stones? (Yes)	Kidney Stones? (No)
Bladder Infection?	Bladder Infection? (Yes)	Bladder Infection? (No)
Protein/Blood in Urine?	Protein/Blood in Urine? (Yes)	Protein/Blood in Urine? (No)
Hearing Loss?	Hearing Loss? (Yes)	Hearing Loss? (No)
Sinusitis?	Sinusitis? (Yes)	Sinusitis? (No)
Irregular Periods?	Irregular Periods? (Yes)	Irregular Periods? (No)
Severe Menstrual Cramps?	Severe Menstrual Cramps? (Yes)	Severe Menstrual Cramps? (No)
Blood Transfusion?	Blood Transfusion? (Yes)	Blood Transfusion? (No)
Bone/Joint/Other Deformity?	Bone/Joint/Other Deformity? (Yes)	Bone/Joint/Other Deformity? (No)
Arthritis?	Arthritis? (Yes)	Arthritis? (No)


	Yes	No
Alcohol/Drug Use?	: Alcohol/Drug Use? (Yes)	Alcohol/Drug Use? (No)
Thyroid Trouble?	Thyroid Trouble? (Yes)	Thyroid Trouble? (No)
Frequent/Severe Headaches?	Frequent/Severe Headaches? (Yes)	Frequent/Severe Headaches? (No)
Severe Head Injury?	Severe Head Injury? (Yes)	Severe Head Injury? (No)
Depression?	Depression? (Yes)	Depression? (No)
Excessive Anxiety/Worry?	Excessive Anxiety/Worry? (Yes)	Excessive Anxiety/Worry? (No)
Intestinal Trouble?	Intestinal Trouble? (Yes)	Intestinal Trouble? (No)
Frequent Vomiting?	Frequent Vomiting? (Yes)	Frequent Vomiting? (No)
Easily Fatigued?	Easily Fatigued? (Yes)	Easily Fatigued? (No)
Overweight/Obese?	Overweight/Obese? (Yes)	Overweight/Obese? (No)
Sexually Transmitted Disease?	Sexually Transmitted Disease? (Yes)	Sexually Transmitted Disease? (No)
Smoking/Vaping?	Smoking/Vaping? (Yes)	Smoking/Vaping? (No)
Learning Disability?	Learning Disability? (Yes)	Learning Disability? (No)
ADD/ADHD?	ADD/ADHD? (Yes)	ADD/ADHD? (No)
Anorexia/Bulimia?	Anorexia/Bulimia? (Yes)	Anorexia/Bulimia? (No)
Other?	Other? (Yes)	Other? (No)

If you answered "yes" to any of the questions above, please specify here:*

Please list all drugs, medicines, birth control pills, vitamins and minerals (prescription and non-prescription) you use and indicate how often you use them.*

Name/Dosage/Frequency

Signature and Authorization

I have personally supplied and/or reviewed the information on this form and attest that it is true and complete to the best of my knowledge. I understand that the information is strictly confidential and will not be released to anyone without my consent unless by court order. However if I should be ill or injured or otherwise unable to sign the appropriate forms, I hereby give my permission for the Student Health Service to release information from my medical record to a physician, hospital or other medical agency involved in providing me with emergency treatment and/or medical care.

Signature*

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Use your mouse or finger to draw your signature above

Student Information

Emergency Contact Information

Health Insurance

Report of Medical History

About Your Family

About You

Report of Medical History (Continued)

Signature and Authorization