1313 Park Boulevard, Rm. A-180 San Diego, CA 92101
(619)388-3450 office (619)388-3098 fax
revised 12/2019
San Diego City College
Student Health Clinic
INTAKE FORM
Student ID#:_____________________________
Name:_______________________________________________________________________________________
First Middle Last
I prefer to be called:_______________________ My preferred Pronouns are:
She/her/hers They/them/theirs
He/him/his Other___________________
Date of Birth:_____________________________ Sex assigned at birth:
Male Other
Female Decline to answer
Email:___________________________________ Cell/Home # (circle one): _____________________________
Address:_________________________________ Zip code:___________________________________________
Emergency contact name: __________________ Relationship to you:__________________________________
Emergency contact phone number:________________________________________________________________
Are you allergic to any medications or substances such as latex?
Yes. If yes, please list and describe reaction_______________________________________________________
No
Are you taking any prescription or over the counter medication(s), and/or herbs or supplements?
Yes. Please list_______________________________________________________________________________
No
Please complete the additional information below:
1. Have you received services at SHC before?
First visit Mental Health Student Health Both
2. Is it okay to leave phone messages to the number listed?
Yes, detailed messages including personal health information such as lab results, prescriptions, etc.
Yes, but only brief messages such as an appointment reminder, or a request to call the clinic.
No, please do not leave messages on my number listed above.
3. Is it okay to send emails to the email address listed?
Yes, detailed emails including personal health information such as lab results, prescriptions, etc.
Yes, but only brief messages such as an appointment reminder, or a request to call the clinic.
No, please do not email me at my email listed above.
1313 Park Boulevard, Rm. A-180 San Diego, CA 92101
(619)388-3450 office (619)388-3098 fax
revised 12/2019
4. Do you have medical insurance?
Yes. If yes, what type of insurance do you have (Medi-Cal, VA, private, etc.)?____________________
No
5. Are you currently being treated for any medical condition(s) or have any disabilities?
Yes. If yes, please list:________________________________________________________________
No
6. Gender:
Male Transgender male/Transman/FTM Gender Queer Other___________
Female Transgender Female/Transwoman/MTF Decline to state
7. Sexual orientation:
Straight Lesbian Other_____________________________________________________
Gay Bisexual Decline to state
8. Ethnicity:
Hispanic or Latino Not Hispanic or Latino Decline to state
9. Race:
White Black or African American American Indian or Alaska Native
Asian Native Hawaiian/Other Pacific Islander Decline to state
10. Marital Status:
Single Married Separated Divorced Widowed Decline to state
11. Do you have children?
Yes No Decline to state
12. What is your major?___________________________________________________________________
13. Do you have sufficient access to meals?
Yes No Decline to state
14. Do you have reliable housing?
Yes No Decline to state
15. Do you belong to one or more of the following programs/groups (circle all that apply)?
EOPS / Former Foster Youth / International Student / Promise Program / Umoja / Veteran /
Received Armed Services Benefits / CalWorks / Price Scholar / Formerly Incarcerated / Puente / HUBU /
Receive SSI
16. How did you hear about us?
For office use only:
Entered into Titanium
Hard chart status
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