Student Health Record Form printable pdf download

STUDENT HEALTH RECORD

(All new students must complete both sides of form. Failure to comply will result in

a hold being placed on future enrollment)

NAME _______________________________________________________________

Male

Female

(Last)

(First)

(Middle)

OBU ID #

Date of Birth _____/ _____/ _____ Cell Phone

Email _______________________

Please write year and circle semester you plan to start: Fall

Spring

J-Term ____

Home Address

PO Box / Street

City

State

Zip

EMERGENCY CONTACT INFORMATION

Name

Relationship

Phone:

Name

Relationship

Phone:

MEDICAL HISTORY-Have you ever had any of the following? (check all that apply)

___ Alcohol Abuse

___ Anemia

___ Arthritis

___ Asthma

___ Back Problems

___ Chronic Cough

___ Cancer

___Colitis

___ Convulsions/Seizures

___ Depression

___ Diabetes

___Disability

___ Drug Abuse

___ Eating Disorder

___ Chronic Hayfever

___ Hepatitis

___ Headache Chronic/Migraine

___ Heart Disease

___ Head Injury

___ Hernia

___ High Blood Pressure

___ High Cholesterol

___ Heart Murmur

___Hemophilia

___ Intestinal/Stomach Disorders

___ Malaria

___ Kidney Disease

___ Mono

___ Menstrual Problems/Pain

___ Orthopedic Problems

___ Pneumonia

___ Polio

___ Psychological Counseling

___ Sickle Cell Disease

___ Rheumatic Fever

___ Mumps

___ Loss of Consciousness/Fainting

___ Sleep Disorder

___ Stroke

___ TB

___ Positive TB Skin Tests

___ Thyroid Disease

___ Spleen Removed

___ Measles

___ Chronic Sinus Infections

___ Chicken Pox

___ Chronic Bladder/Urinary Infections

Brief Explanation of any CHECKED responses:

History of Surgery: specify operations, giving nature, dates and any complications:

List of Current Medications:

Medication Allergies:

YES

(List Medication/Reaction)

Have you been treated for drug or alcohol abuse?

YES

Type of Treatment:

AUTHORIZATION FOR MEDICAL TREATMENT:

Permission is hereby granted to any duly licensed physician and OBU Health

Service to perform emergency treatment and to refer the student to another duly licensed physician, surgeon or dentist for necessary treatment when

indicated.

_____________________________________________________________ __________________________________________________________

Signature of Parent or Guardian of student as a minor

Signature of Student

Date

Note: OBU does not carry health and accident insurance on OBU students. You are urged to carry adequate health and accident insurance.

INSURANCE PLAN

AGREEMENT NUMBER

GROUP NUMBER

ALL INFORMATION PROVIDED IS CONFIDENTIAL

Return this form to: Student Health Services OBU Box 61806 500 W. University Shawnee, OK 74804

Questions? Call Student Health Services, 405.585.5263 fax: 405.585.5266 Monday-Friday, 8am-5pm email: health@okbu.edu

Student Health Record Form

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