Reinhardt University Student Health Services
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6REINHARDT UNIVERSITY
STUDENT HEALTH SERVICES
7300 Reinhardt Circle
Waleska, GA 30183
Office 770-720-5542 Fax 770-720-5901
MEDICAL HISTORY
This is confidential information and will not be released without your written permission.
PART A – TO BE COMPLETED BY STUDENT—DATE______________ Boarding circle YES or NO
I. PLEASE PRINT THE FOLLOWING INFORMATION:
Name: Last_______________________First_________________M.I.___NICKNAME_____________
Birthdate____ /____ /____
SS #_____ /_____ /_____
Sex:
Male
Female
Home Address_____________________________
__________________________
CITY
STATE______________
Student Cell # ______-______-_______ Semester/Year Entering Reinhardt _______ / __________
Home Physician______________________________________ Phone ________-______-__________
Address____________________________________________________________________________
II. INSURANCE COVERAGE
COPY OF INSURANCE CARD MUST ACCOMPANY THIS FORM
**
**
Name of Insurance Carrier____________________________________________________________
Name of Insured_____________________________POLICY #_______________GROUP #________
III. EMERGENCY CONTACTS:
Mother’s Name & #_________________________Father’s Name & #__________________________
Emergency Contact Name____________________Relationship_________________Phone_________
IV. HEALTH HISTORY
1. Please list any allergies: (Drug, Food, Pollen, Insect, Other)_______________________________
2. MEDICATIONS--List the medications you take frequently or regularly
Medication
Dosage
Condition Requiring Medicine
Dr. Prescribing
________
________
________________________
_____________________
________
________
________________________
_____________________
________
________
________________________
_____________________
3. Your Health History – Circle any illnesses that apply to you
Alcoholism
Anemia
Arthritis
Asthma
Back Problems
Bladder Infections
Bleeding Tendency
Bronchitis
Cancer
Colitis
Depression
Diabetes
Drug Abuse
Eating Disorder
Epilepsy/Seizures
Hearing Problems
Heart Problems
Hepatitis
Hypertension
Hypoglycemia
Migraines
Mononucleosis
Pneumonia
Shingles
Thyroid Problems
Tobacco Use
Tuberculosis
Vision Problems
Learning Disability
Other_______________
DATES AND REASON FOR HOSPITALIZATIONS (INCLUDING TREATMENT FOR MENTAL ILLNESS):
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Parent category: Medical