Resident Student Health History And Assessment Form printable pdf download

HEALTH HISTORY AND ASSESSMENT

All Resident students must have a completed Health History and Assessment form on file in Student Health Services prior to registration. If you

have any questions, contact Student Health Services at 516-323-3467.

Please complete all areas and return to Student Health Services, room

K310.

All medical information will be maintained in confidence pursuant to the Family Education Rights and Privacy Act of 1974.

PART 1 (to be completed by student) PLEASE PRINT CLEARLY

Date:

ID#:

Name

Birthdate

Last

First

MI/Maiden

Address

Street

Apartment

City

State

Zip

Home Phone(______)-

____-

_____

Cell Phone(_____)-

____-

______

E-mail _______________

EMERGENCY CONTACT

Name

Relationship

(

-__

(

- _______

Home Phone

Cell Phone

Work Phone

CONSENT FOR MEDICAL/MENTAL HEALTH EVALUATION & TREATMENT OF MINORS – STUDENTS UNDER 18 YEARS OLD

To provide medical/mental health evaluation or treatment to students under the age of 18, parental permission is necessary by law.

I hereby grant permission for my above mentioned minor child / legal ward, to receive mental health services and/or medical evaluation, treatment

and hospitalization in case of accident or illness. I also give permission for the release of information concerning his/her medical condition to other

responsible College officials when necessary, or outside agency, for treatment on an as-needed basis.

Signature of Parent/Guardian (if student is a minor)________________________________________________ Date____________

Have you had any serious accidents, broken bones, or surgical operations? Yes _______ No_______

If yes, please specify and provide dates: ___________________________________________________________________________

__________________________________________________________________________________________________

CHECK ANY ILLNESSES YOU HAVE HAD. (Consult your physician if necessary.)

Frequent Headaches

Pneumonia/Pleurisy (circle which applies)

Diabetes

_____

Epilepsy/convulsions

Tuberculosis

______

Hypoglycemia

_____

Thyroid dysfunction

Infectious mononucleosis

______

Kidney/urinary infection

_____

Cancer

______

Allergy

______

Hernia

_____

Asthma

______

Drug Sensitivity

______

Heart Disease

_____

Anemia

_____

Stomach/bowel difficulty

______

Scarlet fever

_____

High Blood Pressure ______

Hepatitis

______

Skin disorders

_____

Low Blood Pressure ______

Eye/ear/nose/throat infections

______

Bone/joint disease

_____

(circle all that apply)

Rheumatic fever

______

Bleeding disorders

______

Menstrual disorders

_____

Other

______ Describe: _______________________________________________________________________________________

Do you have any physical, (temporary or permanent), or emotional problems of which the College should be aware in order to assist you in the

achievement of your educational goals? Yes _____ No _____

I f yes, please describe: _____________________________________________________________________________________________________

Are there any prescribed or over the counter medications that you require? Yes _____

No _____

If yes, indicate the medication, what you use it for, the dose taken (amount) and the frequency you take it (how often). _______________________

________________________________________________________________________________________________________________________

Are you allergic to any medications? Yes _____ No _____

Are you allergic to any food? Yes _____ No _____

If yes, list all allergies/sensitivities to medications and/or food _____________________________________________________________________

________________________________________________________________________________________________________________________

FAMILY HISTORY (Check all that apply)

Diabetes

______

Cancer

______

Allergy/Asthma (circle which applies) ______

Tuberculosis

______

Heart Disease

______

Anemia

______

Epilepsy

______

Hypertension

______

Blood Disease

______

PLEASE BE SURE TO MAKE COPIES FOR YOUR OWN RECORDS. COPIES WILL NOT BE MADE FOR YOU.

Resident Student Health History And Assessment Form

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