Uc Hastings Shs Personal Health History Questionnaire
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2 UC HASTINGS SHS PERSONAL HEALTH HISTORY QUESTIONNAIRE
In order to allow us to provide you with the best possible care, we are interested in knowing about your medical needs. Please take
the time to carefully complete this personal health history which will be a part of your medical record. It is very useful for our health
care team to have your updated immunization/ shot records as well as any significant medical history. Please call Student Health
Services at 415‐ 565‐ 4612 if you have any questions about your special health care needs before your arrival at UC Hastings.
Your student ID number can be found in Web Advisor.
PERSONAL INFORMATION please print or type
Last Name First Name Middle Initial
Date of Birth
Age
Gender
Student
Telephone Number:
OK to leave message:
ID #
YES NO
Birthplace
Email
Emergency Contact
Relationship (parent/spouse/friend)
Emergency Contact Tel Number
( )
Emergency Contact Address
Street City State Zip
MEDICATIONS List all prescription and over the counter medications, herbs and vitamins you take on a regular basis
Name/Frequency
Name/Frequency
Name/Frequency
___
___
___
ALLERGIES List names of medicines or foods that have resulted in an unfavorable reaction. State reaction.
Medications
___________________________
______________________________________________________________________________
Food or others (latex, insect bites, environmental)
___________________________
______________________________________________________________________________
IMMUNIZATIONS List dates for these immunizations or attach a copy of your immunization record
Most recent Tetanus‐Tdap
Hepatitis B (series of 3)
MMR—measles, mumps, rubella ( 2 in lifetime)
Last TB test and result
Hepatitis A (series of 2)
Meningitis
Polio (OPV, IPV)
Varicella (Chicken Pox)
HPV (Gardasil) (Series of 3)
Other
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