Admissions: Medical History - University of Maine at Fort Kent

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Medical History

Tuition Break for New England Students

Medical History

Information you provide will not be used to influence your situation at the University; it will be used, however, solely as an aid to providing necessary health care while you are a student. This information is strictly for the use of the Health Services and will not be released to anyone without your knowledge or consent.

Required fields are indicated by an asterisk (*)

Please Answer the Following Questions
First Name*:			Last Name*:
Gender:	Male Female		Birth Date*:	Month Day Year
Address*:
City/Town*:		State/Province*:		Zip/Postal Code*:
Country*:			Email*:

Have any of your relatives ever had any of the following:
Tuberculosis:	Yes No	Relationship:
Diabetes:	Yes No	Relationship:
Kidney Disease:	Yes No	Relationship:
Heart Disease:	Yes No	Relationship:
Arthritis:	Yes No	Relationship:
Stomach Disease:	Yes No	Relationship:
Asthma/Hay Fever:	Yes No	Relationship:
Epilepsy, Convulsions:	Yes No	Relationship:

Have you ever had any of the following:
Scarlet Fever:	Yes No	Insomnia:	Yes No
Measles:	Yes No	Frequent Anxiety:	Yes No
German Measles:	Yes No	Frequent Depression:	Yes No
Mumps:	Yes No	Worry/Nervousness:	Yes No
Chicken Pox:	Yes No	Recurrent Headaches:	Yes No
Malaria:	Yes No	Recurrent Colds:	Yes No
Gum or Tooth Trouble:	Yes No	Head Injury/ Unconsciousness:	Yes No
Sinusitis:	Yes No	Eye Trouble:	Yes No
Surgery (explain below):	Yes No	Allergies (explain below):	Yes No
Ear/Nose/Throat Trouble:	Yes No	Pain/Pressure in the Chest:	Yes No
Chronic Cough:	Yes No	Heart Palpitations:	Yes No
High/Low Blood Pressure:	Yes No	Rheumatic Heart Fever/Heart Murmur:	Yes No
Weakness/Paralysis:	Yes No	Venereal Disease:	Yes No
"Trick" Knee/ Shoulder, etc.:	Yes No	Back Problems:	Yes No
Tumor/Cancer/Cyst:	Yes No	Jaundice:	Yes No
Gallbladder/Gallstones:	Yes No	Recurrent Diarhea:	Yes No
Rupture/Hernia:	Yes No	Recent Weight Gain/Loss:	Yes No
Dizziness/Fainting:	Yes No	Disease/Injury of Joints:	Yes No
Frequent Urination:	Yes No	Stomach/Intestinal Trouble:	Yes No
A. Has your physical activity been restricted during the past five years? If yes, give reasons and duration below. Yes No
B. Have you had difficulty with school, studies, or teachers? If yes, give details below. Yes No
C. Have you received treatment or counseling for a nervous condition, personality, or character disorder, or emotional problem? If yes, give details below. Yes No
D. Have you ever had any illness or injury and been hospitalized other than already noted? If yes, please explain. Yes No
E. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past five years? If other than routine checkups, please explain. Yes No
F. Have you ever been rejected for or discharged from military service because of physical, emotional, or other reasons? If yes, please explain. Yes No
Explanations:

For Females Only:
Irregular Periods:	Yes No	Severe Cramps:	Yes No	Excessive Flow:	Yes No
Please verify that all required fields have been filled and that all information is to your knowledge accurate. Once you have looked over the form for accuracy, please submit this form.

University of Maine at Fort Kent • 23 University Dr., Fort Kent, ME 04743

University of Maine at Fort Kent • PO Box 1041, Clair, NB E7A 2J5

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