Fillable Health-History-Questionnaire-Live - Health History Questionnaire

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Health-History-Questionnaire-Live - Health History Questionnaire

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Idaho State University Confidential Health History Questionnaire
Name: _______________________________________________ Bengal ID: ____________________
First Middle Last
ISU Study Abroad Program: ____________________________________________________________
Program Start Date ______________________Program End Date______________________________
Emergency Contact Information
Name: __________________________________________________ Phone: (____) _____-_________
Address: ____________________________________________________________________________
Apt No._____________________________________________________________________________
City______________________________ State________________________ Zip Code_____________
Relationship to Participant: _______________________________________________
Health History
Please list any recent or continuing physical or mental health problems:
___________________________________________________________________________________
___________________________________________________________________________________
Please indicate if you have had any of the following:
Yes ___ No___ Anorexia/bulimia
Yes ___ No___ High blood pressure
Yes ___ No ___ Asthma
Yes ___ No ___ Heart problem
Yes ___ No ___ Hay fever/allergies
Yes ___ No ___ Jaundice/hepatitis
Yes ___ No ___ Back problems
Yes ___ No ___ Protein/sugar in urine
Yes ___ No ___ Bladder/kidney problem
Yes ___ No ___ Ulcers/stomach problems
Yes ___ No ___ Depression
Yes ___ No ___ Epilepsy/convulsion
Yes ___ No ___ Surgery Yes No Diabetes
If YES, please list the type and year of illness
___________________________________________________________________________________
___________________________________________________________________________________
Please explain how you are treating your “yes” responses
___________________________________________________________________________________
___________________________________________________________________________________
Drug Allergies Food/Other Allergies
____ Penicillin Dairy
____ Novocain/local anesthetic Wheat
____ Sulfa Bee stings
____ Other (specify)
Immunization History
Yes ___ No ___ Polio Immunization
Yes ___ No ___ Hepatitis
Yes ___ No___ Measles, mumps rubella
Yes ___ No ___ Chickenpox
Yes ___ No ___ Tetanus booster
Yes ___ No ___ Rabies
Surgery
Yes ___ No ____ Diabetes
Idaho State University Confidential Health History Questionnaire
Confidential Health History Questionnaire (page 2)
Immunizations (cont)
Yes ___ No ___ Yellow fever (required for Ghana)
I understand that I am responsible for obtaining the necessary immunizations for my program
participation. ________ (Initial)
Medicines
Please list any medicines (pills or injections) you take regularly.
____________________________________________________________________
____________________________________________________________________
Tuberculosis
Have you ever lived in close contact with anyone who had tuberculosis? Yes ___ No ___
(if yes, when)___________________________________________
Previous skin test
Negative Year__________
Positive Year___________
Never tested
Family Medical History
Yes ___ No ___ High blood pressure Relation to you:____________________________
Yes ___ No ___ Asthma Relation to you:____________________________
Yes ___ No ___ Heart disease Relation to you:____________________________
Yes ___ No ___ Hay fever/allergies Relation to you:____________________________
Yes ___ No ___ Sickle cell Relation to you:____________________________
Other Medical Conditions Not Listed Above
___________________________________________________________________________________
___________________________________________________________________________________
Current Health Insurance Coverage
Insurance Provider & Policy #_____________________________________________
I affirm that all of the above information is correct and to the best of my knowledge. I am aware of
all personal medical needs, and I state that there are no health related reasons or problems, which
preclude or restrict my participation. I have disclosed all medical, health, or learning conditions, which
may require assistance or accommodation at the program site.
________________________________________ _______________
Printed Name Date
________________________________________ _______________
Signature Date
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Health-History-Questionnaire-Live - Health History Questionnaire

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Completed 4 March 2020

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