Bradley University Required Student Health Form
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1
2BRADLEY UNIVERSITY
REQUIRED STUDENT HEALTH FORM
819 N. Glenwood Ave, Markin Center – Bradley University, Peoria, IL 61625 Ph:(309)677-2700 Fax:(309)677-3534
SEMESTER ENTERING YEAR_________ FA___ SP___FR.
SO.
JR.
SR.
GRAD.
BRADLEY ID#____________________
PLEASE PRINT OR TYPE:
NAME________________________________________________________________________________________________
(LAST, FAMILY SURNAME)
(FIRST, GIVEN)
(MIDDLE, OTHER)
BIRTH DATE:____/_____/___
MALE_____
FEMALE______
SOCIAL SECURITY NUMBER_______-______-________
MO
DAY
YR
HOME ADDRESS__________________________________________________________________________________________
STREET
_______________________________________________________________________________________________________
CITY
STATE
ZIP
PHONE (_____)_____________________
STUDENT CELL PHONE (_____)_______________________
PAST MEDICAL HISTORY
DRUG ALLERGIES_________________________________________________________________________________________
CURRENT MEDICATIONS___________________________________________________________________________________
HOSPITALIZATIONS OR SURGERIES__________________________________________________________________________
MEDICAL CONDITIONS____________________________________________________________________________________
MENTAL HEALTH ILLNESSES________________________________________________________________________________
PLEASE INCLUDE A COPY OF YOUR HEALTH INSURANCE CARD
OR SUMMARY INSURANCE POLICY
IN THE EVENT I WOULD NEED OUTPATIENT LABS, DIAGNOSTIC STUDIES, OR EMERGENCY SERVICES DONE AT ONE OF THE
LOCAL AREA HOSPITALS, I AUTHORIZE BRADLEY HEALTH SERVICES TO UTILIZE:
OSF ST. FRANCIS
METHODIST
PROCTOR
PLEASE CHECK WITH YOUR INSURANCE COMPANY REGARDING COVERAGE IN THE PEORIA AREA
IN CASE OF MEDICAL OR PSYCHIATRIC EMERGENCY OR HOSPITALIZATION, I AUTHORIZE BRADLEY STUDENT HEALTH SERVICES
TO NOTIFY:____________________________
PHONE______________________
PARENTS:
MOTHER________________________________________________
HOME PH (_____)_________________
ADDRESS________________________________________________________ WORK PH (_____)_________________
FATHER____________________________________ _____________ HOME PH (_____)_________________
ADDRESS________________________________________________________ WORK PH (_____)_________________
________
SIGN HERE_______________________________________________________________ DATE__________________
STUDENT SIGNATURE
ATTENTION PARENT/GUARDIAN OF MINOR STUDENTS (students under the age of 18):
I give my permission for the medical staff of Bradley University Student Health Center to diagnose and treat medical conditions that may arise while my child is attending Bradley
University.
SIGN HERE_______________________________________________________________ DATE_____________________________
PARENT/GUARDIAN SIGNATURE
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