Health History Form printable pdf download

HEALTH HISTORY FORM

Tell us about your family’s health history

Relation

Age

If deceased,

Age at

cause of death

death

Please complete your health history form and return by August 1 to:

Father

Student Health Center

Mother

P.O. Box 65

Baldwin City, Kansas 66006

Brothers

785.594.8409

PLEASE INCLUDE:

•COPY OF IMMUNIZATION RECORD

Sisters

•COPY OF INSURANCE CARD

To provide an environment in which student health is

maintained, it is essential to have the information requested.

This form can be completed online at

Has any parent, brother, or sister had:

YES NO if “yes” to any, please explain:

Tell us about yourself

Asthma/hay fever

❍ ______________________________________

❍

Cancer

❍ ______________________________________

❍

Name:

Please print.

Diabetes

❍ ______________________________________

❍

____________________________________________________

Heart trouble

❍ ______________________________________

❍

Convulsive disorder ❍

❍ ______________________________________

Home Address: ________________________________________

Alcoholism

❍ ______________________________________

❍

____________________________________________________

Hypertension

❍ ______________________________________

❍

city

state

zip

Tuberculosis

❍ ______________________________________

❍

Date of Birth __________________________________________

Home Phone # (____)___________________________________

Insurance Information

(Please attach a copy of Insurance Card)

Company _____________________________________________________

Cell Phone # of student (____)__________________________

____________________________________________________________

SSN# _______________________________________________

Address ______________________________________________________

_____________________________ Phone ________________________

Date Entering Baker _____________________________________

Policy Holder __________________________________________________

Gender:

❍ Female

❍ Male

ID# _________________________________________________________

Marital Status:

Group # _____________________________________________________

❍ Single

❍ Married

❍ Widowed

❍ Divorced

Policy Holders SSN # ____________________________________________

Father’s/Spouse’s Name (if married) ______________________________

❍ Traditional Plan

❍ PPO

❍ HMO

❍ Other

Address ___________________________________________________

Physician’s Name _______________________________________________

(if different from above)

Phone ______________________________________________________

Father's/Spouse’s Cell _________________________________________

Do you plan to participate in varsity sports? ❍ Yes ❍ No

Father’s/Spouse’s Employer _____________________________________

Sport: ____________________________________________________

Work Phone _________________________________________________

Student-athletes must complete additional information including a physical

examination by a medical doctor before participation is granted by the Athletics

Mother’s/Spouse’s Name _______________________________________

Department. Forms are available on the sports medicine page of the BU Athletics

website:

Address ____________________________________________________

(if different from above)

International students are required to purchase their health insurance policy through

Baker University when they enroll in classes.

Mother's/Spouse’s Cell

_____________________________________________________

PLEASE COMPLETE BOTH SIDES OF THIS FORM.

Mother’s/Spouse’s Employer ____________________________________

For the (health) record

Work Phone _________________________________________________

Person to Call in an Emergency _________________________________

Relationship ________________________________________________

Phone _____________________________________________________

9/15/2014

Health History Form

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