1313 Park Boulevard, Rm. A-180 San Diego, CA 92101
(619)388-3450 office (619)388-3098 fax
revised 12/2019 revised
San Diego City College
Student Health Clinic
MEDICAL HISTORY FORM
Student ID#:________________
Name: _____________________________________________________ Date of Birth: _________________
Last First MI
ALLERGIES: Yes ( ) No ( ) If yes, please list all allergies: _________________________________________
_________________________________________________________________________________________
CURRENT MEDICATIONS: Yes ( ) No ( ) If yes, please list all medications including over-the-counter
medications, herbs, or supplements: ____________________________________________________________
_________________________________________________________________________________________
HOSPTIALIZATIONS: Yes ( ) No ( ) If hospitalized overnight, please list reason and dates: _______________
_________________________________________________________________________________________
SURGERIES: Yes ( ) No ( ) If yes, please list all surgeries and dates: ________________________________
HAVE YOU HAD PROBLEMS WITH ANY OF THE FOLLOWING?
