Health Form

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 healthcare professionals and only when deemed necessary for your health. YOU WILL NOT RECEIVE A HOUSING ASSIGNMENT UNTIL THIS FORM IS COMPLETED.

Student Information

First Name

Middle Name

Last Name

Student ID

What are your preferred pronouns?

Birthdate

What sex were you assigned at birth?

Female

Male

Prefer not to say

Permanent Mailing Address

Country

Street

City

Region

Postal Code

Email Address

Emergency Contact Information

Name

Relationship

Phone Number

Address

Country

Street

City

Region

Postal Code

Health Insurance

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

Current Physician

Insurance Carrier

Address of Insurance Carrier

Country

Street

City

Region

Postal 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 admissions status. Except in an emergency situation by court order, this information will not be released without your written permission.

About Your Family

If you selected any of the above medical conditions, please provide additional details, including relationship to family member. If you selected "None of the above," write N/A.

About You

If you selected any of the above, please specify here. Otherwise, put N/A.

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).

Report of Medical History (continued)

The following health history is confidential and does not affect your admissions status. Except in an emergency situation by court order, this information will not be released without your written permission.

Have you ever been a patient in any hospital?

Yes

No

Please specify when, where and why.

Has your academic career been interrupted because of physical or emotional problems?

Yes

No

Please explain.

Is there loss of or seriously impaired function of any paired organ?

Yes

No

Please describe.

Other than for a routine check-up, have you seen a physician or health care professional in the past 6 months.

Yes

No

Please explain.

Have you ever had any serious illness or injury other than those previously noted?

Yes

No

Please specify when and where and give complete detail.

Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash, hives, etc.) to any of the following? (check all that apply)

If you checked any of the above, please specify here. Please fully explain the type of reaction, your age when the reaction occurred and if the experience has occurred more than once:

Signature

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