Health History Form printable pdf download

HEALTH HISTORY FORM

ALL students must complete the Health History Form.

Failure to comply with the Student Health Information Requirements may result in your

inability to live on campus, register for classes and/or complete in athletics.

Name:_____________________________________________________________________________________________________

LAST

FIRST

MIDDLE

Date of Birth:________________________ Gender: Male ______ Female _______ Cell Phone # :(

)__________________

Home Address: ____________________________________________________________________________________________

Street

City

State

Zip Code

Emergency Contact Name: _______________________________________

Phone # (

)_________________________

Family Physician: _______________________________________________ Phone # (

)_________________________

PERSONAL HEALTH HISTORY: I have/had the following (Check all that apply):

Condition

Dates and comments

Condition

Dates and comments

□ ADD/ADHD

□ Epilepsy/seizures*

□ Alcohol/substance abuse

□ Heart concerns*

□ Allergies-seasonal or food

□ Hernia

□ Anemia

□ Hepatitis*

□ Anxiety

□ High blood pressure*

□ Asthma*

□ Joint disease

□ Blood disorder*

□ Kidney disease*

□ Bone disease

□ Orthopedic problems

□ Cancer*

□ Pneumonia

□ Chicken pox

□ Psychiatric diagnosis

□ Concussion-head trauma

□ Rheumatic fever

□ Depression

□ Scarlet fever

□ Diabetes

□ Skin disease

□ Diseases of intestinal tract

□ Thyroid condition*

□ Ear infections

□ Tonsillitis

□ Eating disorder

□ Other

Individuals who report as having a chronic condition (marked with *) must also provide a copy of a recent physical. If you are

receiving treatment for any physical or psychological condition, attach a current plan of care including your provider’s

name and contact information.

PERSONAL SYMPTOM HISTORY: I experience the following symptoms (check all that apply):

During Exercise

Dates and comments

Normally

Dates and comments

□ Tire quickly

□ Indigestion

□ Shortness of breath

□ Spitting up blood

□ Dizziness

□ Frequent urination

□ Fainting

□ Eye problems

□ Chest pain

□ Back problems

□ Racing heart

□ Frequent headaches

□ Heart skips beats

□ Weight fluctuations

□ Heat illness

□ Other

Health History Form

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