Name: Date of Birth:
Last MI mm / dd / yyyy
Marital Status: Single Married Separated/Divorced
First
Program start date:
Student Status:
Full-time Part-time
Address:
Street
City State Zip Code
Home Phone:
Work Phone:
Address and phone number during the school year, if different:
Email Address (non-CSP):
Emergency Contact Person:
Name Relationship
Daytime Phone: Evening Phone:
Medical Insurance Name: Policy/ID Number:
Group Name/ Number: Policy Holder:
Address of Policy Holder (if different from self):
Allergies to medications:
Allergies to foods or environment:
Current Medications (prescription & non-prescription, incl. herbal or vitamin supplements, oral contraceptives,
home remedies, etc.) List the medication and why you are taking it:
Medication: Reason for Use:
Medication: Reason for Use:
Medication: Reason for Use:
Medication: Reason for Use:
Date of last Physical Exam: mm/dd/yyyy Date of last Dental Exam: mm/dd/yyyy
Date of last Eye Exam: mm/dd/yyyy Vision: Right Eye: /20 Left Eye: /20
Do you wear Corrective Lenses?
Yes
No Contact lenses?
Yes
No
Vision correctable to 20/20?
Yes
No Corrective Vision Surgery?
Yes
No
Height: Weight:
Student Health History Information
Ever been hospitalized overnight? If yes, where, when, how long, and for what reason:
Ever had surgery? If yes, what type and when:
FAMILY HISTORY
(Mark A&W for alive and well, list any serious health conditions for each person, and if deceased, list age of death, cause of death, and year died)
Mother:
Father:
Siblings:
Student Health History Information
MEDICAL HISTORY Check if you have now or have ever had any of the following:
Alcohol or other drug abuse or dependency
Anemia (iron deficient, sickle cell, etc.)
Arthritis
Asthma
Blood disorders (bleeding/clotting disorders,
stroke, etc.)
Bone fractures
Bowel problems (chronic constipation
or diarrhea/ colitis)
Cancer
Carpal or Tarsal Tunnel Syndrome
Chronic Headaches (Migraine, Tension, etc.)
Chronic Pain
Congenital disorder (Spina Bifida, Cystic Fibrosis,
Cerebral Palsy, etc.)
Diabetes
Eating disorder (Anorexia, Bulimia)
Exposure to hazardous substance (asbestos, lead,
pesticides, radiation, etc.)
G.E.R.D. (Gastroesophogeal reflux disorder)
Head Injury (loss of consciousness, concussion, etc.)
Heart murmur
Heart problems (anomaly, heart arrhythmias,
coronary artery disease, etc.)
Hepatitis
Hernia
Hypertension (high blood pressure)
Joint dislocations
Large number of moles, unusual moles,
difficulty tanning, etc.
Learning Disability (ADD/ADHD, dyslexia, etc.)
Loss of Limbs (from accident or birth)
Loss of Vision, Hearing, Sensation, Smell, or Taste
Menstrual problems
Mental Illness (major depression, anxiety disorder,
bipolar disorder, etc.)
Mobility Problems (paraplegia, quadraplegia, etc.)
Pelvic Inflammatory Disease
Rheumatic Fever
Seizures or Epilepsy
Sexually Transmitted Disease
Skin problems (eczema, psoriasis, etc.)
Spinal Problems - Neck or Back (injury, scoliosis, etc.)
Tuberculosis
Ulcers (Stomach or Intestinal)
Urinary Tract Problems (bladder/kidney, infections,
kidney disease, etc.)
Other (chronic or recurring illnesses such as asthma
or malaria, etc.)
Dates/Comments:
UAM-0814-0233
Alcoholism/Chemical dependency
Cancer
Have any of your blood relations had any of the following:
Diabetes
Heart disease (especially onset before age 50)
Hyperlipidernia (high cholesterol)
Hypertension (high blood pressure)
Mental Illness (depression, Bipolar, Schizophrenia, etc.)
Osteoporosis
Sudden unexplained deathxpl
Scoliosis
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