Louisiana Tech University Medical History
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3For Office use
______________
Initials
Louisiana Tech University
Student Health Center
P.O. Box 3023
Ruston, LA 71272
Phone: (318)257-4866
Fax: (318)257-3927
Email: health@latech.edu
MEDICAL HISTORY
Student Information (Please Print)
All information is confidential and is reviewed by Health Center Personnel only.
Name_______________________________________________________________________________________________________
(
Last)
(First)
(Middle)
Social Security # or Student ID: ____________________________ Date of birth ______/______/_____ Age ________ Sex _____
Address_____________________________________________________________________________________________________
(
Street)
(City)
(State)
(Zip Code)
Telephone: (____) __________________Cell: (_____) ________________ Email:_________________________________________
Emergency Contact Information
Name: ________________________________________________________ Relationship: __________________________________
Home Phone: (____) __________________ Work Phone: (____) ___________________ Cell Phone: (____) ____________________
Family History
Has any member of your family ever had any of the following? (Please check)
___Asthma or Hay Fever
___Cancer
___Convulsions/Seizures
___Diabetes
___Heart Disease
___High Blood Pressure
___Kidney Disease
___Mental Illness
___Rheumatism(arthritis)
___Sickle Cell
___Stomach, Intestinal Trouble
___Tuberculosis
Personal History
List any surgeries: ___________________________________________________________________________________________
List any medical conditions you are currently being treated for:________________________________________________________
List any medications you take on a regular basis:____________________________________________________________________
List any serious illnesses: ______________________________________________________________________________________
List any food or drug allergies: __________________________________________________________________________________
Comments: __________________________________________________________________________________________________
____________________________________________________________________________________________________________
Insurance
Type
Company
Accident and Hospitalization
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