Student Medical History Form

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.

Name(Required)
Birth Date(Required)
Address(Required)

Have any of your relatives ever had any of the following:

Tuberculosis
Arthritis
Diabetes
Stomach Disease
Kidney Disease
Asthma or Hay Fever
Heart Disease
Epilepsy/Convulsions

Have you ever had any of the following:

Scarlet Fever
Frequent Depression
Measles
Worry/Nervousness
German Measles
Recurrent Headaches
Mumps
Recurrent Colds
Chicken Pox
Head Injury/Unconsciousness
Malaria
Eye Trouble
Gum or Tooth Trouble
Allergies
If yes, please explain in the Explanations field below.
Sinusitis
Pain/Pressure in the Chest
Surgery
If yes, please explain in the Explanations field below.
Heart Palpitations
Ear/Nose/Throat Trouble
Rheumatic Fever/Heart Murmur
Chronic Cough
Venereal Disease
High/Low Blood Pressure
Back Problems
Weakness/Paralysis
Jaundice
"Trick" Knee/Shoulder, Etc.
Recurrent Diarrhea
Tumor/Cancer/Cyst
Recent Weight Gain/Loss
Gallbladder/Gallstones
Disease/Injury of Joints
Rupture/Hernia
Stomach/Intestinal Trouble
Dizziness/Fainting
Frequent Urination
Irregular Periods
Severe Period-Related Cramps
Excessive Period Flow:
Frequent Anxiety
Insomnia
Has your physical activity been restricted during the past five years?
If yes, give reasons and duration in the Explanations field below.
Have you had difficulty with school, studies, or teachers?
If yes, give details in the Explanations field below.
Have you received treatment or counseling for a nervous condition, personality, or character disorder, or emotional problem?
If yes, give details in the Explanations field below.
Have you ever had any illness or injury and been hospitalized other than already noted?
If yes, please explain in the Explanations field below.
Other than routine checkups, have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past five years?
If yes, please explain in the Explanations field below.
Have you ever been rejected for or discharged from military service because of physical, emotional, or other reasons?
If yes, please explain in the Explanations field below.

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.

This field is for validation purposes and should be left unchanged.