Connecticut State University Student Health Services Form Page 4
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4Connecticut State University Student Health Services Form
Page 2
PLEASE RETAIN A COPY OF THIS HEALTH FORM FOR YOUR RECORDS BOTH SIDES/PAGES OF THIS FORM MUST BE SUBMITTED
Student Name
Home/Personal Email Address
Student Cell Phone
Permanent Home Information
Notify in Case of Emergency
Home Phone
Cell/Work Phone
Name
Relationship
Street Address
Home Phone
Cell/Work Phone
City
State
Zip
Street Address
City
State
Zip
Personal Physician/Healthcare Provider
Address:
Name:
Telephone #:
FAX #
Personal Medical History
- Please circle all below that apply to you
Check here if none apply
Alcohol/drug Abuse
Diabetes
Mumps
Anxiety/depression/mental illness
Endometriosis
Rheumatic Fever
Asthma
Gastrointestinal Problems
Seizures
Cancer
Hepatitis B or C Disease
Sickle Cell Anemia
Cardiac Condition/Heart Murmur
High Blood Pressure
Thyroid Disorder
Coagulation Disorder
HIV/AIDS
Tuberculosis
Concussion
Measles
Other please explain
Dental Problems
Mononucleosis
Allergies: Drugs & Other Severe Adverse Reactions
-
Please complete all that apply and explain reaction
Check here if you have no allergies
Medication
Food
Insect
Environmental
Seasonal
X-ray Contrast
Are any life threatening?
Yes
No
Do you carry an Epi Pen?
Yes
No
Prior Hospitalizations or Surgeries - Please list dates and reasons
Medications – Frequent or regular- Please list all prescriptions, natural and over the counter medications
Is there any other medical information or health concern that we should know about? Please attach any additional information to
further explain your condition or concern.
Current Height**:
Current Weight**:
Last Blood Pressure (if known)**:
**not required
Did you sign the Consent for Treatment on Page 1?
Please return by mail or fax to the appropriate Health Service listed below.
Central Connecticut State University
Eastern Connecticut State University
Southern Connecticut State University
Western Connecticut State University
University Health Service
University Health Service
University Health Service
University Health Service
1615 Stanley Street
185 Birch Street
501 Crescent Street
181White Street
New Britain, CT 06050
Willimantic, CT 06226
New Haven, CT 06515
Danbury, CT 06810
860/832-1925 Fax 860/832-2579
860/465-5263 Fax 860/465-4560
203/392-6300 Fax 203/392-6301
203/837-8594 Fax 203/837-8583
Revised 06/19/2014
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Parent category: Medical