Directions For Completing Medical Requirement Forms (Page 3 of 8) in pdf

Health History (to be completed by student)

Name: _____________________________________Student ID: ______________DOB: _________________________________

Address: _________________________________________City/Province: ______________________Phone (h): _____________

Emergency Contacts, two (Name, relationship, telephone number and alternate numbers)

______________________________________________________________________________

Family History: (Please check off those that apply. If indicate who has a history. Example: maternal grandmother, paternal

uncle)

___ High blood pressure

___ Kidney disease

___Asthma

___ Stroke

___ Bleeding disorders

___ Tuberculosis

___ Cancer

___ Seizures

___ Colitis

___ Emphysema

___ Heart disease

___ Anemia

___ Ulcers

___ Diabetes

___ Mental illness

___ Gout

___ Other (list) ______________________________________________

Lifestyle: (please indicate and briefly describe)

Sleep patterns: ________________________________________ Do you often feel rested? _____________________________

Appetite: Poor ____ Fair ____ Good ___ Special Diet: Y/N If yes, explain ____________________________________________

Smoker? Y/N #/day: __________# of years smoked:____________Alcohol: Y/N #/ week ___________________Caffeine: Y/N

Recreational Drugs: Y/N Frequency: _____________Type(s): _____________________________________________________

Exercise Y/N Type: ___________________________________________________ Frequency: __________________________

Reproductive History (Female only)

Age of menarche: __________ Start date of last normal period __________ Are your menses regular? Y/N

How often do they occur? _________________ How long do they last? ___________________________

Any problems with your menses? (explain) __________________________________________________

Current Health Status:

Do you currently have any health problems? If yes, explain ________________________________________________________

Are you currently on medications? If yes, please list ______________________________________________________________

Do you have any allergies? If yes, please list and type of reaction:

________________________________________________________________________________________________________

Do you have an emergency medical plan for your allergies? Ie) Benadryl or Epi-pen? ___________________________________

Do you have a medic alert bracelet? Y/N

Medical Form

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Directions For Completing Medical Requirement Forms Page 3