University Health Service
Division of Student Affairs
10900 Euclid Avenue
Cleveland, Ohio 44106-4901
Phone 216.368.2450
Fax 216.368.8530
Health Service Occupational Health Medical History
healthservice@case.edu
Employee Information
students.case.edu/health
Name _______________________________________________________________________
Last
First
Middle/Maiden
Home Address ________________________________________________________________
Street
City
Zip Code
Home Telephone # _____________ Date of Birth ___________
Male
Female
MM/DD/YYYY
Position ________________ Department _______________ Supervisor ___________________
Campus Telephone # _________________ Email Address ______________________________
In Emergency Notify ______________________________ Telephone # ___________________
Address _____________________________________________________________________
Have you ever worked at Case Western Reserve University?
Yes
No
Has your name changed?
Yes
No
Please give previous name ________________
Medical History
Current physicians or clinics attended:
Name _________________________________________________________________
Address _______________________________________________________________
Allergy History:
Medicine/Drugs _________________________________________________________
Foods, Insects, etc. _______________________________________________________
Medication/Drugs taken regularly __________________________________________________
Have you had or do you now have? (Please check all that apply)
Seizures
Heart disease
Muscular dystrophies
Diabetes
Bone or joint pain
Arthritis
Backache (chronic)
Varicose veins
High blood pressure
Cancer
Black out spells
Stroke
Loss of eye sight
Amputation
Blood clots
Circulation problems
Bleeding problems
Tuberculosis
Neurological problems
Immune system disease
Breathing problems
Multiple sclerosis
Disability/Rehabilitation
Hepatitis/Jaundice
Parkinson’s disease
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