REPORT OF HEALTH EVALUATION
Return to:
ASU Health Center Student ID Number ______________________________
P.O. Box 271
Montgomery, AL 36101 Semester to Enroll Summer Fall Spring 20 ________
THIS PAGE TO BE COMPLETED BY STUDENT
Full Name ____________________________________________________ Birthdate ________________ Sex/Gender ______
(Last) (First) (MI) (Mo) / (Date) / (Yr)
Home Address _______________________________________ Email Address _____________________________________
City_____________________________________________________________ State ______________ Zip ______________
Telephone Numbers: ___________________________________ (home) _______________________________________(cell)
In case of medical emergency, notify __________________________________________ Relationship ________________
Name
Address _______________________________________________________ City _______________________ State_______ Zip _______
Telephone Number: ____________________(cell) _____________________________ (work) ______________________(home)
MEDICAL HISTORY
1. Do you have any medical problems? (ex., asthma, diabetes, high blood pressure, lupus, sickle cell disease, seizures, etc.)
Yes___ No ___ If yes, please explain __________________________________________________________________
_______________________________________________________________________________________________
2. Have you consulted a physician or been hospitalized within the past five years? Yes ___ No ___ If yes, please explain
______________________________________________________________________________________________
______________________________________________________________________________________________
3. Please list any surgery(s), acute or chronic illnesses, and significant injuries which you have had including dates
______________________________________________________________________________________________
______________________________________________________________________________________________
4. Have you ever been treated for mental or emotional disorders? Yes ____ No ___ If yes, please explain _____________
______________________________________________________________________________________________
______________________________________________________________________________________________
5. Are you taking any medications regularly at the present time, or have you taken any in the past (including allergy
injections, antidepressants, contraceptives, etc.)? Yes ___ No ___ If yes, please list ___________________________
______________________________________________________________________________________________
6. Are you allergic to any medications, foods, or other substances? Yes ___ No ___ If so, list and describe reactions
______________________________________________________________________________________________
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Health Center Use Only: Hold ______________________________________
Status ____________________________________________ HLD Released _________________________________
