Uab Student Health And Wellness Health History Form
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4UAB Student Health and Wellness
Health History Form
Learning Resource Center
th
rd
1714 9
Avenue South, 3
Floor
Birmingham, Alabama 35294-1270
(205) 934-3580
Please save this form and upload it to .
Entering Semester: ☐ Fall ☐ Spring ☐ Summer
Year_______
UAB Student No. __B______________
General Information
Gender: ☐ Male
☐ Female
Full Name:
_____
☐ Transgendered ☐ Transitional
Last
First
MI
Date of Birth: Month:
Day:
Year: ____________
School:
Program or Major Code: ___________________________________
CAS, Med, Dent, SHP, Nurs. etc.
Education, History, Physics, Biology, etc.
Current Email address:
__
___________
Blazer ID: _ _ ___________________
Are you an International Student or Scholar? ☐ Yes ☐No
If Yes, which country? ____________________________
Telephone number: _________________
__________
Height: __
____
Weight:__________
Home
Cell
Local Address: _
____________________________________________________________________________
Permanent Address _________________
____________________________________________________________
Primary emergency contact:
Telephone number:
Relationship: ___
____
Secondary emergency contact: ______
_____Telephone number:
Relationship: __
____
Personal Health History
Medical Conditions
Please list any surgeries, asthma, diabetes, ADHD, injuries, hospitalizations, etc.
Name
Description
Year
Medications
Please list prescription, non-prescription, vitamins, birth control, etc.
Name
Description
Dosage
Food/Medicine Allergies
Please list penicillin, codeine, insect bites, antibiotics, specific food or chemical, etc.
Name
Description
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Parent category: Medical