Health History Form Page 2
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5MEDICATION INFORMATION: I take the following prescription and/or over the counter medications or supplements.
Drug Name
Condition
Dosing
Comments
ORTHOPEDIC HEALTH HISTORY: I have/had injuries to the following (Check all that apply):
Condition
Dates and type
Condition
Dates and type
□ Spine
□ Pelvis
□ Shoulder
□ Thigh
□ Forearm
□ Knee
□ Elbow
□ Lower leg
□ Neck
□ Ankle
□ Wrist
□ Foot
□ Hand
□ Toes
FAMILY HEALTH HISTORY: I have/had family members with the following (Check all that apply):
Condition
Dates, relation and comments
□ Cancer
□ Diabetes
□ Heart Disease
□ Kidney Disease
□ Tuberculosis
□ Sudden death under age 50
□ Other
OTHER HISTORY:
Other than that listed above, I have/had the following surgery, illness or health condition: _________________________________
_________________________________________________________________________________________________________
I have allergies to these medications: ___________________________________________________________________________
Please check any that apply :
_____ I require vision assistance
_____ I require hearing assistance
_____ I require academic assistance
_____ I have a medical condition that requires special housing considerations
_____ I have a medical condition that has special dietary concerns
Other comments, concerns or items to share with the Student Health Center: ___________________________________________
_________________________________________________________________________________________________________
Student Signature:___________________________________________________ Date:_______________
My signature above indicates that all statements are true to the best of my knowledge. My signature above also permits the Student
Health Center to share pertinent health information with those who have an immediate need, except where I have indicated below.
DO NOT SHARE INFORMATION WITH:
_____Resident Assistant
_____ Athletic Staff
_____ Director of Student Support
_____ Dining Staff
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Parent category: Medical